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TOWN OF SOUTH WI N DSOR . .
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fDEPARTMENT OF PUBLIC WORKS
�J/(J/ BUREAU OF POLLUTION CONTROL
DRAIN LAYER'S PERMIT -
1
I Pursuant to"written application, permission is hereby gra ted to the Lice ed Drain Layer
named herein to perform the wgrk �nd ca ed below at b; S
at premises' owned!!<.by b whose dress is
and to'
Lay House Drain, ` Repair Hdo e''Diain, Lay Main, Other, ,
for � _
ticE'upancy 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 tie issued for (�%�✓ '
the holder of Drain, Layer';s •License No. Permit will expire thirty (30)'rdays,
after date of issuance. The undersigned Drain Layer hereby agrees 'to all the terms_,�a ndJ
conditions set forth in the permit and the reverse side thereof. Applicant has , I d
Town Permit Na. and/or .C,HD Permit No. _
Signed
-Licensed- Drain Layer'
The above named Drain Layer has a valid license issued b the State of Connect ��-fend
has filed a satisfactory bond and .insurance policy, ,in.. e n e of 'the Town "Windsor:
r, /y
4; ' if ,��
- - _
` Engineering Department
/ 5-0. D.O ; ?ate B
.-..�....-•ems,
Connection Charge Paid' - Permit Feel.' Paid
Check Number
ax .ice
� NSP ON
- _ - - -- - -
�, wor started + Date completed
`suficient notification received: Yes No
-__Special. Conditions
APPROVED:
/� Inspector Date .