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TOWN OF SOUTH WI N DSOR
DEPARTMENT OF PUBLIC WORKS
BUREAU OF POLLUTION CONTROL
n ` n DRAIN LAYER'S PERMIT NNO, 4980
191
Pursuant to written application, permission is hereb granted to the Licens rain Layer
named herein to perform the work��"n Gated Belo at %/ -- 5; �
at premises owned by c..v�-r�-� 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� propogework or furnish two (2) copies of separate drawings. �
3�
57
7 � a
SPECIAL CONDITIONS
Desired Starting Date Z -uI_. 8j Estimated Time for Completion Wo/j(J7S
Permit to be issued to ( � ��� � ,� JSt C ti.It .
the holder of Drain Layer's License No. 2-67'741j Permit wily 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. f
Signed
Licensed Drain Layer
The above named Drain Layer has a valid licensesissued by the State of Connecticut and
has filed a satisfactory bond and insurance policy in the name of the Town of South Windsor:
Engin Bring Department Date
i
Connection Charge Paid . G!`Z~ ��g zal Permit Fee: Paid $ 3
Check Number dp V 2
Issued by d�
t
Tax Office
INSPECTION
Date work started Date completed
Sufficient notification received: Yes No
--Special_Conditions
APPROVED:
Inspector pate