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C'ootrt of 0114 Ivitthoor
Department of Pollution Control
SOUTH WINDSOR, CONNECTICUT'
DRAIN LAYER'S PERMIT
Application for Permit to Install or Repair Individual Sewage Disposal System
Fee Paid $............ ?��,t?+`% By .:.,::7 z ;.... , .t ,, .d..:i�.:l.............................................. Permit No.
�............... .. .:r.:.... .................... ........ .................
Date ....................................::'s,................,..`:,..........
Pursuant to written application, permission is hereby granted to the Licensed Drain Layer named herein
for repair ......... or construction ;:... of an individual sewage disposal system concerning which the following
information is submitted:
1. Owner of Property ...........:..T ............................................................................. Address of Owner ...................................................................................................
2. Location of Property ...10;. ..........;°:: ., • Lot No.
3. Type of Structure ...............;!It _,
�..;:;:; ............................................................................................................... ............ .......
(Dwelling, Commercial Building, Store, etc.)
4. Number of Families or Persons to Occupy Premises ..........f: u;.....�.:;.}.....:::.;ri. ry.;r...................................................................................................
5. Number of Bedrooms ..:;'s __,::....(.;';•..................
6. Average Daily Flow ...................................................
Manufacturer and
7. Liquid Capacity of Septic Tank ...............i ,..? r E t r ,.,::Material of Septic Tank ....... :::..;.............,..,::.:.
8. Soil Conditions: Type of Soil .....................................................................................................................................................................................................
...........................
(Sand, Gravel, Clay, etc.)
Maximumground water table ..............................................................................................................................................................................
9. If not served by public water supply:
Distance from Owner's well ...............................................
Fromadjacent wells .......................................:.....................................................
10. Distance to nearest water course, drainage ditch, storm drain or embankment ...................
..........
11. Percolation Tests: Time for 1" drop in soil test . ,:7..: +,E ,_;>_.. ( ; ... , �,,
�. •a
Classification of soil ........................................
................
12. Minimum square feet of effective seepag area required , 4.. t ..:. ,.,,..:....:��, , ,
........................
13. Leaching System: Number of trenches ...,Q.atA...<A)............... Length .....3a.9,..fT ................. Width ......J0 .10:r.....................
Total ........47 ems...... Other ............................................................... .
14. Plot Plan Attached. ....... ;.
15. Layout Approved
16. This permit expires ,
Signature .......:.....................:
r (Licensed Drain Layer)
Installation Completed, Inspected and Approved in accordance with State Public Health Code and Local Ordinances
49y awAr AM 4.1.
.................................................................0..9....-nl................... 19...2:Y..... By
...................... . .................................................................................................
Pollution Problem abated Date ................................:.............................................
Inspector
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NOTES SOUTH WINDSOR POLLUTION CONTROL
�Z LOCATION
R 34 43 sd OWNER
6 43 4- 3s TYPE OF WORK S
IC-
DATE o9-o - 7�- PERMIT z- PIPE "
INSTALLER g --a
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