HomeMy WebLinkAboutDrain Layers Permit 67 Mountain Drive TOWN OF SOUTH WI N DSOR
DEPARTMENT OF PUBLIC WORKS
BUREAU OF POLLUTION CONTROL
' qua 52
DRAIN LAYER'S PERMIT ���;
19 �?o
Pursuant to written application, permission is hereby granted to the Licensed Drain Layer
named herein to perform the work indicated. below at 7 114 o(4 A-)_r79/A/ 0
at premises owned by Go/L/ ce--)�q whose address is
6 7 I v u Al OTC and to
Lay House Drain, Repair House Drain, Lay Main, Other ,
for occupancy or use, with 0 N E
Family Units, with acres.
Type of Sewage to be connected under this permit: SANITARY SEWAGE (V/ , INDUSTRIAL
WASTES ( ), OR ( ) Connection will be made with
Show sketch of proposed work or furnish two (2) copies of separate drawings.
0-0
A�f
90
PV
�7- 6-9�
/Y/ OUN 72])
SPECIAL CONDITIONS
Desired Starting Date /2 - ( - Cj O Estimated Time for Completion /2 - - U
Permit to be issued to -/ M &JqL K,2F/Z _ 5kl RS 5,e-p77 SCR vIc �
the holder of Drain Layer's License No. a2 O 7 7 02 Permit will expire thirty (30) days
y
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. Ap licant has received
Town Permit No. and/or CHD Permit No. �-
/.; a
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 Department Date
Connection Charge Paid
g t--:C O Permit Fee: Paid $
Check Number
Issued by
Tax Office
INSPECTION
Date work started !Z _ �l�a Date completed
Sufficient notification received: _f Yes No
Special Conditions
APPROVED:
Inspector pate
TOWN OF SOUTH WINDSOR
SANITARY SEWER LATERAL FIELD LOCATION
zzx�4
owN�2
BUILDING ADDRESS OR LOT Ng : 7 /ylOUn/7xl v T,c
STREET:
SUBDIVISION-
0
Mi STATION : +
NORTH ARROW INVERT ELEV:
TIE TIE
-FT -FT
HOUSE LATERAL LATERAL HOUSE
CONNECTION STUB STUB CONNECTION
FT. FT.
BUILDING INV. ELEV. INV.ELEV. INV. ELEV. INV. ELEV. BUILDING
(IF EXIST.) U.
(IF EXIST.)
TIE TIE
PM STATION
INVERT ELEV:
CONTRACTOR (PRINT) NAME OF CONTRACTORS SUPERVISOR(PRINT)
STREET ADDRESS SIGNATURE DATE
TOWN STATE ZIP INSPECTED BY TOWN DATE
C
TELEPHONE NUMBER
WHITE - TOWN PINK - CONTRACTOR YELLOW -CONSULTING ENGINEER/DEVELOPER
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