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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
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Application No.
TO THE BUILDING DEPARTMENT: Date. tl P—1-1,Q 19 Eric
A permit is requested for repair o construction of an individual sewage disposal system concerning which the
following information is submitt�'
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1. Owner of Property Address of
Owner
2. Location of PropertyLot. No.
3. Type of Structure l
(Dwe ommercial Building,Store,etc.) No. of Bedrooms_
4. Number of Families or Persons to Occu
py emises_
5. Plumbing Fixtures: Water Closets 7 Urinals Lavatories Bathtubs /
Showers_ Kitchen Sinks__ Laundry Tubs Garbage Grinder Other
6. Liquid Capacity of Septic Tank la C Material of Septic Tank__
7. Soil Conditions: Type of Soil Q> Maximum ground water table
(Sand,Gravel,craly,etc.)
8. If not served by public water supply: Distance from Owner's well_tea 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 � �r Classification of soil
11. Minimum square feet of effective seepage area required Z:�
12. Leaching System: Number of trenches .. Length_rIEEL�. Width 2 Total r
Other
Signature T
(Licensed Installer)
(Sketch showing all minimum distances and other details required below)
Permit Issued 19 By
Installation Completed, Inspected and Approved 19 By
FnR Rim-nim'I--MIRPOSES ONLY
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