HomeMy WebLinkAboutDrain Layers Permit 35 Brian Road TOWN OF SOUTH WI N DSOR
DEPARTMENT OF PUBLIC WORKS
BUREAU OF POLLUTION CONTROL
DRAIN LAYER S PERMIT , 5938
Pursuant to written application, permission is hereby granted to the
Lice' ed Drain Layer named herein to perform the work i7dica\e ow at
�TAC\T-. at premises owned by t,.�
whose address is _m and to
Lay House Dr in� Repair House Drain, Lay Main, Other ,
for ��� , .�► , occupancy or use, with
Family Units, with J acrese
Type of Sewage to be connected under this permit: SANITARY SEWAGE (- ,
INDUSTRIAL WASTES ( ) , OR.. ( )
Connection will be madeswith
Show sketch of proposed work or furnish 'two (2) co,pi sCe arate drawings.
1/ � 1 c6r o � l ll , P1.9 S� r
SPECIAL CONDYTIONS
OSHA REQUIREMENTS MUST BE FOLLOWED
��a,•�.i
Desired Starting Date Estimat d Time for Completion
Permit to be issued to � rvwle
the holder of Drain Layer's License No. .2f-,a(.3 7f Permit will expire thirty
(30) days after date of issuance. The undersigned Drain Layer hereby agrees
to all the terms and conditions set . forth in the permit and the reverse side
thereof . Applicant has received Town Permit No. and/or
CHD Permit No.
Signed
Licensed Drain Layer
The above named Drain Layer has a val d license issued by the State of
Connecticut and has filed a satisfactory bond and insurance policy in the
name of the Town of South Windsor: ,
4/rf�l9 �
n ine ng Dept . Date
Permit Fee Paid $ '4y Check Wumber L' F
Connection Charge Receipt No. b Dated ` -'
Issued by 47%/g
INSPECTION
Date work started — !�_�eSte completed l.� - Z3=g�
Sufficient notification rece ve .-
Special Conditions
APPROVE
Inspector Date
OF SOUTH WIPDSOR
_ SANITARY SEWER INSPECTION CHECKLIST
FUNCTION ` - -Z g 3I , 5 3$ NO YES N/A DATE INSPECTED
1. Is Permit On Job Site
2. Police Notified
3. Safety Items In Place °pa90
a. Shoring, Trench Box, Ladder _
b. Hard Hats _
C. Pumps _
4. Proper Material
a. Pipe
b. Pipe Bedding AE
c. Backf ill _
d. Warning Tape _
e. Pipe Cap or Plug
f . Cleanouts _
g. Fittings _
h. Manhole
i. Cover & Frame
5. Existing Lateral Cap Removed _
in Presence of Inspector
6 . Lateral probed and found
to be clear
7 . Pavement Cut Properly
8 . Trench & Bedding OR
9 . Joints Properly Done
10 . Backfilling (12" Lifts)
& Compaction
11. Manhole Inverts Built
12 . Subbase Material Placed
13 . Base Material Placed
14 . Blacktop (Temp) w/Proper
Grades & Slopes
15 . Pressure Test
16 . Mandrel Test
17 . Installation agrees with plan
18 . As-Built plans recorded _
TOWN OF SOUTH WINDSOR
SANITARY SEWER LATERAL FIELD LOCATION
DATE OF CONSTRUCTION: aa �3
BUILDING ADDRESS OR LOT N° : S
STREET: mare
SUBDIVISION:
NH STATION : +
NORTH ARROW ) j INVERT ELEV:
03 -1`rdrrt Gvt.'
TIE T I E
FT -FT
HOUSE LATERAL LATERAL 71 -FT.
HOUSE
NNECTION . STUB STUB CONNECTION
FT.
BUILDING INV. ELEV. INY.ELEV. INVU. . ELEV. INV. EL BUILDING
(IF EXIST.)
� 'PWA (IF EXIST.)
&JOT TIE TIE
(�O
Mq STATION : +
INVERT ELEV:
anig-.5- t,
no Uri►.�r S �di�►�2-� rU(Ate—
CONTRACTOR (PRINT) NAME OF CONTRACTORS SUPERVISOR(PRINT)
7T ,50/ban Av/ 03
STREET ADDRESS GNATUR DATE
5n, C_r ��i7q
TOWN STATE ZIP INSPECTED BY TOWN DATE
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C � E //,,//ttq
TELEPHONE NUMBER
WHITE - TOWN PINK - CONTRACTOR YELLOW -CONSULTING ENGINEER/DEVELOPER