HomeMy WebLinkAboutDrain Layers Permit 31 Linda Lane TOWN OF SOUTH WINDSOR
DEPARTMENT OF PUBLIC WORKS
BUREAU OF POLLUTION CONTROL
DRAIN LAYER'S PERMIT
Pursuant to written application, permission is hereby 'granted to the
Licensed, Drain Layer named herein t-o perform the work indicated below at
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 propos d w r or furnish 'two (2) copies of 7,v;wr
w gs.
SPECIAL CONDITIONS OSHA REQUIREMENTS MUST BE FOLLOWED
Desired Starting Date Estimated Time for Completion
Permit to be issued to
the holder of Drain Layer ' s License No. r?`; 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
Licensed Drain Layer
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:
Engineering Dept . Date
Permit Fee Paid $ Check Number
Connection Charge Receipt No. Dated
Issued by
INSPECTION
Date work started Date completed
Sufficient notification rece ve : es No
Special Conditions
APPROV r ZX��
•Inspector Date
TOWN OF SOUTH WINDSOR
SANITARY SEWER INSPECTION CHECKLIST
FUNCTION NO YES N/A DATE INSPECTED
1 . Is Permit On Job Site
2 . Police Notified
3 . Safety Items In Place
a. Sh-u ox, Ladder X
b. Hard Hats X
C . Pumps
4 . Proper Material
a . Pipe X
b. Pipe Bedding X
C . Backfill
d. Warning Tape
e. Pipe Cap or Plug
f . Cleanouts
g. Fittings
h. Manhole
i . Cover & Frame
5 . Existing Lateral Cap Removed X
in Presence of Inspector
6 . Lateral probed and found
to be clear �(
7 . Pavement Cut Properly �l
8 . Trench & Bedding OK
9 . Joints Properly Done x
10 . Backfilling (12" Lifts )
& Compaction
11 . Manhole Inverts Built
12 . Subbase Material Placed
13 . Base Material Placed
14 . Blacktop (Temp) w/Proper
Grades & Slopes
15 . Pressure Test
16 . Mandrel Test
17 . Installation agrees with plan - ,`-
18 . As-Built plans recorded
TOWN OF SOUTH WINDSOR
SANITARY SEWER LATERAL FIELD LOCATION
DATE OF CONSTRUCTION:
BUILDING ADDRESS OR LOT N2 :
STREET:
-S-U-B-D-1 V I-S 10 N
G Mi STATION :
NORTH ARROW INVERT ELEV:
0 i
TIE TIE
,4
-- -FT VA -FT,
HOUSE LATERAL LATERAL
X= _HOUSE
CONNECTION j STL41,:V,. STUB CONNECTION
FT FT.
BUILDING INV. ELEV. INV.ELEV. INV. ELEV. INV. ELEV.
(IF EXIST) U. BUILDING
(IF EXIST.)
TIE TIE
fM STATION :-+
INVERTELEV:
2 k
CONTRACTOR (PRINT) NAME OF CONTRACTOR'S SUPERVISOR(PRINT)
STREET ADDRESS /sll A -UFit /
DATE
TOWN STATE
ZIP INSPECTED BY TOWN DATE
TELEPHONE NUMBER
WHITE - TOWN PINK CONTRACTOR YELLOW -CONSULTING ENGINEER/DEVELOPER