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TOWN OF SOUTH WINDSOR
DEPARTMENT OF PUBLICWORKS
j% BUREAU OF POLLUTION CONTROL
DRAIN LAYER'S PERMIT O 6221
v• L�q�n� �or•
_2 19
Pursuant , '
to written application, permission is hereby granted to granted to Licen ed rain Layer ame herein to perform the work indicated bel w� at
at ptemis s o ned ,by
who a address. is a ' to
Lay House Drain,, Repair se Drain, Lay Main, Other
for occupancy or use, with jh
Family Units , with '; acres. 40/
Type of 'Sewage to 'be ' connected under th SANF�ARY SEWAGE
INDUSTRIAL WASTES 02R 4 ,per It,
Connection will be made with S' 3 ` SekaELV, r
Show sketch of proposed work or furnish t o (2) 'co ies o s pay e drawings.
li
OSHA REQUIR�FMENTS MUST BE FOL OWED
SPECIAL C 0 N D I T.I 0 N S (�?�/ G� ,yt�, ha '0,w��o
Desired Starting Date / ,+�g�.-yy' Estimated Time for Completion
Permit' to' be issued to 'a5
the holder of. Drain Layer ' s License No. 2"gyW Permit will expire thirty
( 30) days after date of issuance. The undersigned' Drain_ Layer hereby agrees
to all the terms and co-nditions, set forth in the permit and the reverse side
thereof . Applicant ha,s,. received Town Permit No , and/or '
CHD- Permit No .
Signed 6Lea,4
L cen d Droaln Layer
The above named Drain Layer has a valid license issued by the State of
Connecticut and . has filed a ;setisfactory bond and insurance policy in the
--name of the Town of South - ndsor'
1 i7 /z,-Z'3 -gy
Engineering Dept. Date
Permit Fee Paid $ !1:.00 Check Number ���,� q
Connection Charge Receipt No. 62;> Dated tal a 2-41
Issued by
INSPECTION
Date work started 2Z- Date completed 2.- Z.Z-19,
Sufficient notifica on rece ve _Yes No
Special Conditions A '
APPROV �fL
Inspecto-r Date
SANITARY LATERAL & EXCAVATION PERMIT
INSPECTION REQUEST
DATE OF REQUEST: jZ, - 2,2 -!2tL TIME:
BY:. V !(C.f�17 FOR LOCATION:
DAY INSPEC. NEEDED �}' a `�-Z.-q TIME:
TYPE OF INSPECTION:
SANITARY/LATERAL PERMIT NO. FOOTING DRAIN
( ) EXCAVATION (PERMIT NO. ) ( ) OTHER
INSPECTION REPORT
DATE: 1 Z - 2.Z - TIME: 9 j 11 / INSP:
CONTRACTOR: WEATHER: (VO,,
G
WORK IN PROGRESS:
A L5t
M '
•
AREA OF CONCERN:
SPECIAL INSTRUCTIONS: