HomeMy WebLinkAboutDrain Layers Permit 125 Ellington Road (2) E APPLICATION FOR DRAIN LAYERS PERMIT 695�
TOWN OF SOUTH WINDSOR
PUBLIC WORKS DEPARTMENT
TOWN HALL
1540 SULLIVAN AVENUE
SOUTH WINDSOR, CT
FEE$25.00
Location of proposed work / � '//;ag a Lot #
Street No. Street Name
Premises owned by: DS7
Name of Firm: xk�,. �w� Phone: gtoo
Address of Firm P tp „6 1p COO eT
TYPE OF WORK:
Lay House Drain Repair House Drain ;
Lay Main ; Lay Lateral for CommerciaVIndustrial
Building of acres
Connection will be made with
Proposed Start Date 3 i-7 stimated time for completion
ALL WORK TO BE IN ACCORDANCE WITH TOWN OF SOUTH WINDSOR
STANDARDS, ALL OSHA REQUIREMENTS AND CONDITIONS ATTACHED TO
THE PERMIT
Permit is to be issued to )f— the holder of Drain
layer's License No. PO-Zoo.-ZwZ . Only holders of Pl, P7 & W9 licenses will be
issued a permit. 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 attached thereto. Applicant has received Town Street
Excavation Permit No. and/or ConnDOT Permit No.
Signed: Print Name t�
Licensed Drain Layer
Date:
TOWN OF SOUTH WINDSOR 70b *t-
SANITARY SEWER LATERAL FIELD LOCATION
DATE OF CONSTRUCTION:
BUILDING ADDRESS 62 4-otx toinJ(So r
STREET : Ell rh 4-a pv
SUBDIVISION: _ 607PUT Te 0
NORTH ARROW
:
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CONTRACTOR (PRINT) 4 NATAE OF CONTRACTOR'S SUP RVISOR (PRINT)
77 eckWau i Krook Rd
STREET ADDRESS SIGNATURE
Le�//` n c7' DATE
TOWN STATE ZIP INSPECTED BY TOWN
F-7,5- - S?9' 2 DATE
TELEPHONE NUMBER
WHITE - TOWN PINK - CONTRACTOR YELLOW - CONSULTING ENGINEER / DEVELOPER
TOWN OF SOUTH WINDSOR INSPECTION REPORT
PROJECT:
DEVELOPER-/ JT
STREET: ! CONTRACTOR:
4, .f3�2 4�ac cx G
DATE: TDAE: C? ' c9c> ,
WEATHER: INSP:
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WORK IN PROGRESS:
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AREA OF CONCERN:
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ukftl��5� po V-s "j f F.C> ac1T A 6 TTt .
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SPECIAL INSTRUCTIONS: