HomeMy WebLinkAboutDrain Layers Permit 328 Burnham Street TOWN OF SOUTH WINDSOR
t` DEPARTMENT OF PUBLIC WORKS
, BUREAU OF POLLUTION CONTROL
DRAIN LAYER'S PERMIT ;� 9
/2—
Pursuant to written application, permission is hereby granted to the Licensed Drain Layer
named herein to perform the work�ndicated below at 3 Z 1-30 ✓-v Cc
at premises owned by A ✓ / J�-�C i1 �✓ whose address is
and to
Lay House Drain, Repair House Drain, -Lay Main, Other ,
for occupancy or use, with
Family Units, with acres.
Type of Sewage to be connected under this permit: SANITARY SEWAGE INDUSTRIAL
WASTES ( ), OR ( ) Connection will be made with
Show sketch of proposed work or furnish two (2) copies of separate drawings.
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SPECIAL CONDITIONS
Desired Starting Date -3 — ; Z i' Estimated Time for Completion 2-
/)
Permit to be issued to ; %`
the holder of Drain Layer's License No.-) 0 > o 5-1 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' rain Layer
The above named Drain Layer has a valid 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:
Mt
Engineering p
Department Date
Connection Charge Paid Permit Fee: Paid $
Check Number rJ t
Issued by
Tax Office
INSPECTION
Date work started Date completed
Sufficient notification received: Yes No
Special Conditions
APPROVED:
Inspector Date
TOWN OF SOUTH WINDSOR
SANITARY SEWER LATERAL FIELD LOCATION
DATE OF CONSTRUCTION: /2— a /�
BUILDING ADDRESS OR LOT N2 :
STREET:
SUBDIVISION: r,/6
C)
NH STATION : +
NORTH ARROW INVERT ELEV:
TIE TIE
FT FT
HOUSE LATERAL LATERAL _ HOUSE
71_ ST
CONNECTION UB ` STUB CONNECTION
FT. FT.
BUILDING INV. ELEV. INV.ELEV. INV. ELEV, INV. ELEV. BUILDING
(IF EXIST.) IF (IF EXIST.)
TIE TIE
M-1 STATION : +
INVERT ELEV:
CONTRACTOR (PRINT) NAME OF CONTRACTORS SUPERVISOR(PRINT)
/y 2/UP/� 5✓ c:--�= /Z// 1,
STREET.ADDRESS SIGNATURE DATE
(A_)rN,ex_
TOWN STATE ZIP INSPECTED BY TOWN DATE
(2-0.3 ) OFF -/2-
TELEPHONE NUMBER
WHITE - TOWN PINK - CONTRACTOR YELLOW -CONSULTING ENGINEER/DEVELOPER