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TOWN OF SOUTH WI N DSOR
BUILDING DEPARTMENT
South Windsor, Connecticut
Application for Permit to Install or Repair Individual Sewage Disposal System
Application No.
TO THE BUILDING DEPARTMENT: Date, 19Z
A permit is requested for repair or construction of an individual sewage disposal system concerning which the
following information is submitted:
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1. Owner of Property ('./�-�'� ""� ✓ " Addres" s of Owner
2. Location of Propert�� tip✓`-0LV Lot. No.
3. Type of Structure t No. of Bedrooms_
(Dwelling,Commercial Building,Store etc)
4. Number of Families or Persons to Occupy Premises_ �Z,
5. Plumbing Fixtures: Water Closets '2 Urinals Lavatories Bathtubs
Showers_ Kitchen Sinks L Laundry Tubs Garbage Grinder Other
6. Liquid Capacity of Septic Tank Material of Septic Tankk�-i/1
7. Soil Conditions: Type of Soil c 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, storm drain or embankment
10. Percolation Tests: Time for 1" drop in soil test Classification of soil
11. Minimum square feet of effective seepage area required `)
12. Leaching System: Number of trenches Length �7 Width /Y Total .S L e9
Other
Signature �� r
Licensed Install r)
(Sketch showing all minimum distances and other details required below)
Permit Issued 19 BY '
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Installation Completed, Inspected and Approved 19 By
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