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BUILDING DEPARTMENT
South Windsor, Connecticut d
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Application for Permit to Install or Repair Individual Sewage Disposal System �Q3�
Application �No.
TO THE BUILDING DEPARTMENT: Date l-e •gw, 19.6L
A permit is requested for repair or construction of an individual sewage disposal system concerning which the
following information is submitted:
1. Owner of Property iz L, �S�Address of Owner
2. Location of Property 5�►1V 157 Lot. No. 2
3. Type of Structure pl.a<_c(/(/ b' No. of Bedrooms
(Dwelling,Commercial Building,Store,etc.)
4. Number of Families or Persons to Occupy Premises_ -' °ram r:zf�
5. Plumbing Fixtures: Water Closets ! Urinals Lavatories /' Bathtubs
Showers ! Kitchen Sinks,` Laundry Tubs Garbage Grinder— Other. LL _�
6. Liquid Capacity of Septic Tank S C 10
L Material of Septic Tank C0// �'-
7. Soil Conditions: Type of Soil-7 Maximum ground water table
(Sand,Gravel,Clay,etc.)
8. If not served by public water supply: Distance from Owner's well �� (./from adjacent wells
9. Distance to nearest water course, drainage ditch, m d st rrain or embankment��
10. Percolation Tests: Time for 1" drop in soil test 04::&rl'C V Classification of soil " �e
?: oc
11. Minimum square feet of effective seepage area required
12. Leaching S,ydem: Number of trenches ,� Length L M-Widtl. Total
Other
Signature C
icensedris ler
a (Sketch showing all minimum distances and other details required below)
- Pt per
Permit Issued 19 By
Installation Completed, Inspected and Approved Q(a -;/077_—/-1,G Fi2_ 19 6 By
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