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TOWN OF SOUTH WINDSOR
DEPARTMENT OF PUBLIC WORKS
BUREAU OF POLLUTION CONTROL
DRAIN LAYER'S PERMIT (/ O 4347
19' ./.
Pursuant to written application, permission is hereby granted to the,Licensed Drain Layer
named herein to perform the work indicated below ate of( ?
at premises owned by whose address is
J, �, <' and to
Lay House Drain, vRephir House Drain; Lay Main, Other ,
for I occupancy or use, with
Family._ its, 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.
I
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 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 (/ IL � "
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:
ng nee ing Department Date
onnection C arge Paid Permit Fee: Paid
�F
Check Number
/z T J Q C'2� -- -
• c 7,� C. C �' Issued_ by- -
Tax Office
INSPECT-ION
a e work sta-fEeZI bare comp ete
Sufficient notification received: Yes No
--Spec-lal Conditions
APPROVED:
Inspector pate