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TOWN OF SOUTH WI N DSOR
DEPARTMENT OF POLLUTION CONTROL B/P No.:
South Windsor, Connecticut
List.No.: _
DRAIN LAYER'S PERMITS " 3171
gL 9 , 19
Pursuant to written a catior, permission is hereby granted to the Licensed Drain Layer named herein to perform
the work indicated below at
on the
side, b tween
at premises owned by
whose address is
and to Lay House Drain, Repair House Drain; Lay-Main, Other
for occupancy 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
Permit.to be issued to
the holder of Drain Layer's License No. Permit will expire on 19
The undersigned Drain Layer hereby agrees to all the terms and conditions set forth on the permit and the reverse side
thereof. Applicant has received Town Permit No. and/or C H D Permit No.
for street excavation.
SPECIAL •CONDITIONS
n h `7 Signed
onnection Charge Paid (/Q. 0 �-�u 4 Licensed Drain Layer
• T Cp�lect 1t�C�V f � "`t �'r`�� Permit Fee: Paid $
INSPECTION: ---Check-Number...
- INITIAL (Sig)
FINAL (Sig)
APPROVED (Date)
(Sig)
INSPECTOR