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TOWN OF SOUTH WI N DSOR
DEPARTMENT OF PUBLIC WORKS
BUREAU OF POLLUTION CONTROL ''((����
DRAIN LAYER'S PERMIT 1�T1.. 4140
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Pursuant to written application, permission is hereby grnted to tl}e Lic sed Drai Layer
named herein to perform he work indicate below atr
at premises owned by
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 proposed work or furnish two (2) copies of separate drawings.
SPECIAL CONDITIONS
Desired Starting Date Estimated Time for Completion
Permit to be issued to
the holder of Drain Layer's License 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. b c /-.
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 the name of the Town of South Windsor:
I �
Engineering Department Date
Connection Charge Paid 14 G Permit Fee: Paid $ U+'
11 Check Number
Issued by
�J
Tax Office
INSPECTION
Date work started Date completed
Sufficient notification received: Yes No
Special Conditions
APPROVED:
Inspector Date