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HomeMy WebLinkAboutDrain Layers Permit 2800 Ellington Road TOWN OF SOUTH WINDSOR C05�j DEPARTMENT OF PUBLIC WORKS BUREAU OF POLLUTION CONTROL DRAIN LAYER'S PERMIT y 5 7 f Pursuant to written application, permission is hereby granted to the Licensed Drain Layer named herein to perform the work indicated below at ;�,7 C5,; 00 L:t t_ l3� at premises owned by i6` /�/�Si7 / + whose address is and to Lay House Drain, _!rf Repair House Drain, Lay Main, Other , for ^�:,, =C = >,,,i,_ i; occupancy or use, with Family Units, with acres. Type of Sewage to be connected under this permit: SANITARY SEWAGE (z, INDUSTRIAL WASTES ( ), OR ( ) Connection will be made with Show sketch of proposed work or furnish two (2) copies o separa a rawings. 0,1 L. jam, s c�/trt LliJl %c; jt/�c„i > v SPECIAL CONDITIONS : Desired Starting Date Estimated Time for Completion 7 , Permit to be issued t0 /1✓�J�'ly/r?�✓ < .a7 .'[: ;,�. �Ci7/VU� ;r the holder of Drain Layer's License No. 7r, J . 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 -�/��ryL2c Licensed Drain L der 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: jEngin. ering epartment — Date - Connection Charge Paid •,� �,� � � t'r 1`, Permit Fee: Paid $ -� = 00 Check Number Issued by Tax Office i ! i INSPECTION Date work started Date completed Sufficient notification received: Yes No Special Conditions APPROVED: Inspector Date Date: Form No. PMT-1 Rev, 4/84 Application form must be + `. State of Connecticut filled in completely and 1 9D ` Department of Transportation mailed or delivered to the Fee: (for DOT use) Bureau of Highways Bureau of Highways District { Office. APPLICATION FOR PERMIT LOCATION OF PROPOSED WORK: ,v (a) Town: (b) Route: 7 (c) Street Name&No: aLWO iC t (d) (Circle One) N. S. E. WGside of Highway. (e) Located Between Utility Poles No. -:2`r V3 & No. (f) Distance and direction from nearest intersecting road. Milel© S. E. W.)of —44,LL — (St49 Application is hereby made to: (Describe fully&include sketch or attach plans)ZOR_ZZ ST fl L 4Tian/O{ SfWf-R 4i9i F.1<ift_ l4PPl;ox. 78'� Sn�7y �,C fi ✓h'o�-f �n/�r.'cnT �. ffvr� /�J/,ir//':�/ %s f,/{T.SioF_ o{P,9 �_"A/�C�'�!/fir✓ &/YCAi iT ,G " W&W ORIV6WA-V i 7o 1.0,T Roque Gu7 �. � y in! 1+�Rtts1 LINE — - Orr �cgcl ft go �E !�'66 -�- ,sNrr i gr PERMIT FEE can be paid only by check or money order payable to Treasurer - State of Conn. Name of Surety Company & amount of Bond Permit to be issued to: ESS ZPJG CO, Name: /-477.)L /Pft 81?jOIl H6E S i/I/C_ . Party to whom bond is issued: & Print Name �A 71,,4-/I0Pe 8,To C-PI& mt Signed hone �6—' /4L Address: D y£�'i 11/Onl S 1 Party to whom Insurance is Issued: Town: X14A/Cd67-ER Or Zip 00'O Print Name / L i 0101HER S 11VC The owner of the property for whom this work is being performed agrees to accept all future maintenance responsibility Signedc Phone 6 �— I j' for the work specified in the permit. Approximate Time Required Desired Starting� print Owner's name ��9Sh'�� ,���ti/ G Date,6� GcoQ Complete Plans and Specifications must be submitted Address: for major encroachment permits. On other work a 7"UL4i9/' CT' careful sketch shall be.shown in space above or on back side a, c� of application. Signed: Phone