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TOWN OF SOUTH WI N DSOR
p / BUILDING DEPARTMENT
0 South Windsor, Connecticut
/ Application for Permit to Install or Repair Individual Sewage Disposal System
Application No.
TO THE BUILDING DEPARTMENT: Date, G 19*e4l,
A permit is requested for repair-or construction of an individual sewage disposal system concerning which the
following information is suJ fitted: ��,,��
1. Owner of Property ` a e95!41-b— Address of Owner o2,�/ , /CsG
2. Location of Prop t ob• Lot. No.
3. Type of Structure No. of Bedrooms
(Dw7emises_
Commercial Building,Store,etc.)
4. Number of Families or Persons to Occupy 3
5. Plumbing Fixtures: Water Closets / Urinals Lavatories / Bathtubs_
Showers_ Kitchen Sinks I Laundry Tubs__L Garbage Grinder,� Other /
6. Liquid Capacity of Septic Tank kJ_%5_D Material of Septic Tank
7. Soil Conditions: T tZOM& ground water table 9
Type of Soil Maximum
(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 /tlOy�
10. Percolation Tests: Time for 1" drop in soil test Z n! /,? Classification of soil
17
11. Minimum square feet of effective seepage area required
12. Leaching
/System: Number of trenches Length Width Total 1 /
Other /(�f�G�i�Y2l % xe /D Xel fr' Dce T 2v
ex cr
Signature
(Licensed Installer)
(Sketch showing all minimum distances and other details required below)
NIP I°
4 4JXe_
Permit Issued 19 By
Installation Completed, Inspected and Approved 19 By