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TOWN OF SOUTH WI N DSOR
DEPARTMENT OF PUBLIC WORKS
BUREAU OF POLLUTION CONTROL
DRAIN LAYER'S PERMIT O 4199
/ ��SS CQ t J l 19
Pursuant to written application, permission is hereby granted—to the LicerW ed Drain Layer
named herein to perform the work indicate below at J /J�
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
--
Show sketch of proposed work or furnish two (2) copies of separ� ings.
N
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SPECIAL CONDTTIQNS
,- 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 ag ees to 11 the terms and
conditions set forth in the permit and the reverse side there f. App cant has received
Town Permit No. and/or CHD Permit No.
Signed AA
JiCens Drain Layer
The above named Drain Layer has a valid license is ued by the State of Connecticut and
has filed a satisfactory bond and insurance policy ' the_ name of the T� of South Windsor:
Q/ Engineerin Department Date
Connection Charge Paid - � J/�Clo Permit Fee: Paid $ �. d
(% Check Number 3
/. Issued by
/ 4 Tax office
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INSPECTION
—Date work started �. `� .. : a - completed
Sufficient notification received: es ( No
Special Conditions
- s
APPROVED: — Z d-
Inspec Date