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TOWN OF SOUTH WI N DSOR
RTMENT OF PUBLIC WORKS
/ U OF POLLUTION CONTROL
/ (0 DRAIN LAYER'S PERMIT ,-e2 56 9 6,
IJ ov I ;L , 19al
Pursuant to written application, permission is hereby granted to the Licensed Drain Layer
named herein to perform the work I dicatgd below at P�ca�N P, foo �� r _ 1�oT 9
at premises owned by (j icy-wl-, ��, ( �{ rs whose address is
'�3k C;"? V)F-S`r `T^,.fin c.i iUoRu)ic,4 c t and to
Lay House Drain, Repair House Drain, Lay Main, Other ,
for occupancy or use, with S
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 proposedwork or furnish two (2) copies of separate drawings.
77- Av- �wz,u c7> I L-A-7�j
SPECIAL CONDITIONS
Desired Starting-Date Estimated Time for Completion
Permit -to be issued to �Q��,� ��\ 1 .9�,t _ ��)13E (_x(_Au klorn E ScrVILE:s
the holder of Drain Layer's License No. Q� o3(,Z.(�. 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. 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 i th name of Atr)e Town of South Windsor:
i I�11l I
Faig neeri4g epartment Date
Connection Charge Paid t cf '� IC' ` Permit Fee: Paid $ 2�
Check N4nber 0 Z07>4
Issued by
Tax Office
i
INSPECTION
Date work started Date completed
Sufficient notification received: Yes No
Special Conditions
APPROVED:
Inspector Date
• TOWN OF SOUTH WINDSOR
SANITARY SEWER LATERAL FIELD LOCATION
DATE OF CONSTRUCTION: I 'il 'e1
BUILDING ADDRESS OR LOT N° : �
STREET: LN-
SUBDIVISION: fef} 6pzoc
NH STATION : L2 +
NORTH ARROW INVERT ELEV: )Uo 3t
l) I
N
TIE c , TIE
-FT F T.
HOUSE _ LATERAL LATERAL HOUSE
CONNECTION STUB STUB CONNECTION
FT. ' I7 FT.
BUILDING INV. ELEV. INV.EL V. � INV. ELEV. INV. ELEV. BUILDING
(IF EXIST.) (IF EXIST.)
I
,r TIE J TIE
W STATION : +
>
�EWC"Yt� WIH � INVERT ELEV: l 6 ZJ
&LDI7�C4rlyj. At46E ektomlO � � I
CONTRACTOR (PRINT) NAME F CONTRACT:%S� SUPERVISOR (PRINT)
G-i s►31rr>- c cl o fI,O. �. !4 2S� t
STREET.ADDRESS- SIGNATUR DATE
S. LA)INI5� C1Z CT,
TOWN STATE ZIP INSPECTED BY TOWN DATE
( 203 ) 5Z8-?3z.3 7
9S`��Z5'ol
TELEPHONE NUMBER
WHITE - TOWN PINK - CONTRACTOR YELLOW -CONSULTING ENGINEER/DEVELOPER