HomeMy WebLinkAbout23SITE1 689OCR Septic App Rec 021723Permit #
Application for Site Testing and the Installation of Sewage Disposal Systems
Property Location: Town: Street: Street #: Lot #: Owner: Phone No: Address: Owner’s Email address: Installers Name: License #: Expiration date: Company Name: Address: Phone No: Installers Email address: No of Bedrooms: Use of Structure:
Garbage grinder/disposal? No Yes Whirlpool/Oversized tub? No Yes # of Gals. Non-residential design criteria: Flow GPD
Within 200 ft. of: A public water supply? Yes No A public sewer? Yes No Water Supply: Public Well
Footing Drain: Yes No Curtain Drain: Yes No In-ground Fuel Tank: Yes No Easements on Lot: Yes No On a Flood Plain?: Yes No Wetlands: Yes No Within 100 ft of a Watercourse or Pond: Yes No
Site Testing - $100.00/lot New System Subdivision No. of lots $ Additional Testing - $75.00/lot No. of lots $
Septic Repair/Renovation Testing - $75.00 $
Perc Testing Fill - $50.00 $ Groundwater Monitoring - $100.00 $ Sewage Disposal System Permit - New Residential System $125.00
Commercial System $150.00 Transfer or Renew Permit $50.00 Residential System $100.00: Repair Septic Tank Sewer Line D-Box $
Plan Review - Residential $75.00 w/1 rev. Commercial $150.00 w/1 rev. Subdivision/Site Plan 1 lot w/ 1 rev $75.00
Subdivision/Site Plan 2 or more lots w/1 rev. $100.00 # of lots Well Only $25.00 Revisions $25.00/lot # of lots $
Total Fee Due: $ Fee Paid: $ Cash: Check #: Receipt #: Date:
Fee Paid: $ Cash: Check #: Receipt #: Date:
Signature of Installer: Date: See Reverse Revised 5/28/2020
The installer must present a copy of his current license and sign the application in person at the District office.
A set of house plans must be submitted with the application for new construction.
The applicant for site testing must arrange for a backhoe and supply 10 gallons of water on-site.
A minimum of 4 test holes and a perc test, in the primary and reserve areas, are required per lot.
An accurate plot plan, to scale, must accompany the application.
The fee must be submitted with the application prior to testing the lot.
For District Use Only
Soil tests conducted (date):
Area of Special Concern: Yes No If yes, reasons: Engineered plan required: Yes No
If yes, Name of Engineer:
Address of Engineer: Design Plan Approved (date): Approved By:
Date of Approved Plan: Revision Date:
Well Permit Approved (date): Well Driller’s Name:
Well Driller’s Address:
Permit to Construct Issued (date):
401 West Thames Street – Ste. #106, Norwich, CT 06360
Telephone No. (860) 823-1189 FAX No. (860) 887-7898
E-Mail: office@uncashd.org
Internet: www.uncashd.org