HomeMy WebLinkAboutDrain Layers Permit 1031 Main Street Lx
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DEPARTMENT OF PUBLIC WORKS
BUREAU OF POLLUTION CONTROL:
DRAIN ZAYER'S-P-ERMIT- - --
Pursuant to written application,.. permission -is hereby granted to the
License Drain L yer ,1named herein to perform the work indica d-be w a
v u�/1 ha�Y►'� / �31 y A"Kat premises owned by xG r, u ✓'-7 /e,k-i
whose address is Sr Yh and to
Lay Hous Dr ,in, Repair Hou-se Drain, Lay Main, Other
fork - — occupancy or use, with
Family. Unts, with acres. '
Type of Sewage to be connected under this permit SANITARY SEWAGE (-10) ,
INDUSTRIAL WASTES ( ) , OR
Connection will be made with ,A ti
Show sketch of proposed work or fs" ish 'two (2) copies of separate drawings.
� POPr
F OSHA REQUIREMENTS MUST BE FOLLOWED
SPECIAL CONDITIONS
Desired Starting Date Estimate Time for Completion' ,
Permit to be issued to
the holder of Drain Layer's Men se' 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. y'
Signed
L cens Drain Layer
The above named Drain Layer has a val 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 Deptf, Date
Permit Fee Paid $ a 5 ,Oct Check Number
Connection Charge Receipt No. � Dated
Issued by
INSPECTION
Date work" started eL zz
Este compNeoted .-
Sufficient notifica on r ce ve
Special Conditions
APPROV
Inspector Date
_ TORN OF SOUTH W33IDSOR
SANITARY SERER INSPECTION CHECKLIST
" F CTION 9 NO YES N/A DATE INSPECTED
1. Is Permit On Job Site 6 /�
2. Police Notified
3 . Safety Items In Place
a. Shoring, Trench Box, Ladder
b. Hard Hats
C. Pumps
4 . Proper Material
a. Pipe
b. Pine Bedding u
C. Backfill
d. Warning Tape
e. Pipe Cap or Plug
f . Cleanouts
g. Fittings
h. Manhole
i. Cover & Frame
5 . Existing Lateral Cap Removed
in Presence of Inspector
6 . Lateral probed and found
to be clear
7 . Pavement Cut Properly
8 . . Trench & Bedding OR
9 . Joints Properly Done
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
y TOWN_ .OF SOUTH W-INDSOR _ -
SANITARY SEWER LATERAL FIELD LOCATION
DATE OF CONSTRUCTION:
BUILDING ADDRESS OR LOT No: �� I
STREET: M61%) 54
t
Mi STATION : +
NORTH ARROW INVERT ELEV:
TIE TIE
-FT -Ft
HOUSE LATERAL LATERAL HOUSE
CONNECTION c /STUB STUB CONNECTION
_7
F T.
12_ :I-FT.
BUILDING INV. ELEV INV.ELEV. INV. ELEV, INV. ELEV. BUILDING
IF EXIST.) Tj
(I F EXIST.)
TIE TIE
gm C
ZI -2 Ll Mi STATION : +
INVERT ELEV:
S l rIJU, � U,�A ,, r
CONTRACTOR (PRINT) NAM OF CONTRACTORS SUPERVISOR(PRINT)
STREET ADDRESS SflqWATURIE DAT6A o�7V .4/1/04 5_ 6 -2Z
--STATE --- -- 21P - ---- I-NSPECTE6 BY TOWN - - -------DATE
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TELEP-HONE NUMBER
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