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__TOWN - OF SOUTH---WI N DSOR_
'y
DEPARTMENT OF PUBLIC WORKS
BUREAU OF POLLUTION CONTROL
DRAIN LAYER'S PERMIT `,y 563J,
/ 19` /
Pursuant to written application, permission is hereby granted to the Licensed-Drain Layer
named herein to perform the work indicated below at
at premises owned by zzy;, -� i�,�� whose address is
and to
Lay House Drain, L__-- 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 separate drawings.
SPECIAL CONDITIONS
Desired Starting Date y Estimated Time for Completion
Permit to be issued to
the holder of Drain Layer's License No. ���,, �%5�. 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 X�c.' �,;lG�
Li nsed 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 ', fthe name of the Town of South Windsor:
r�-
,Cf Engineering Department Date
Connection Charge Paid < � Permit Fee: Paid $
Check Number
Issued by
Tax Office_
INSPECTION
Date work - ---- .:
tatted /y Dane completed
Sufficient notification received: �_ Yes No
Special Conditions
APPROVED: Z 2
Inspector Date
t
TOWN OF SOUTH W I N DSOR
4
SANITARY SEWER LATERAL FIELD LOCATION
DATE OF CONSTRUCTION:
BUILDING ADDRESS OR LOT N' :
STREET:
SUBDIVISION:
NH STATION : +
NORTH ARROW INVERT ELEV:
LL
TIE TIE
i
`p F T "F T.
HOUSE 1$� HOUSE
LATERAL LATERAL
CONNECTION STUB STUB CONNECTION
FT. FT.
BUILDING INV. ELEV. INV.ELEV. INVU. . ELEV. INV. ELEV. BUILDING
(IF EXIST.) I I (IF EXIST.)
TIE TIE
W STATION : t
INVERT LEV:
CONTRACTOR (PRINT) N ME OfF CONTRACTORS SUPERVISOR(PRINT)
1,,V s
STREET ADDRESS SaAE DATE
TOWN - - STATE- - -- ZIP _ INSPECTED BY TOWN- --_ _ _ _ DATE
TELEPHONE NUMBER
WHITE - TOWN PINK - CONTRACTOR YELLOW -CONSULTING ENGINEER/DEVELOPER