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TOWN OF SOUTH WI N DSOR
DEPARTMENT OF PUBLIC WORKS
BUREAU OF POLLUTION CONTROL c�1
DRAIN LAYER'S PERMIT 4211
PIZ?
'' 19 `
Pursuant to written application, permission is hereby granted to the Li ensed Drain Layer
named herein to. perform the wo ,k indicated below aLt /.d��t t�((ir�''<; ,T i, ._V_ 0Q S
at premises owned by ( l f r;,1 S is; %t C'.l�/r; j!.`� 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.
SPECIAL CONDITIONS
Desired Starting Date Estimated Time for Completion
Permit to be issued to
the holder of Drain Layer's License No. Permit will expire thf`A -:(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 yer
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:
Engineering Department Date
Connection Charge Paid J fl {� `jib Permit Fee: Paid
Check Number
f Y! l j,J� r� _16 /�f�" r ! U (.k` Issued by
Tax 6ffice
INSPECTION
Date work started Date completed
Sufficient notification received: Yes No
Special Conditions
APPROVED:
Inspector pate
t