HomeMy WebLinkAboutDrain Layers Permit 510 Quarry Brook Dri l X TOWN OF SOUTH WINDSOR
DEPARTMENT OF PUBLIC WORKS
BUREAU OF POLLUTION CONTROL
51 O Quarrq )kvoP ULA.� , YER'S PERMIT 5955
�f Y 04,fin_ I , 19
Pursuant to1written application, permission is hereby granted to the
Licensed Drain Layer named herein to perform the work indicated below at
0 at premises owned by
whose address is .c z,, ir/ and to
Lay House Drain, Repair House D -ain, Lay Mai , Other
for occupancy or use, with
Family U its, wit 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.
OSHA REQUIR�MENTS MUST BE FOLLOWED
SPECIAL CONDITIONS
Desired Starting Date r1_ Estimated Time for Completion /
Permit to be issued to
the holder of Drain Layer's Licen a No. Z - Permit will expir thirty
(30) days after date of issuance. The undersign d 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 �IA
Licensed Dri n Lay r
The above named Drain Layer has a valid license issued by ge State of
Connecticut and has filed a satisfactory bond and insurance policy in the
name of the Town of South Windsor:
c�
in i ring Dept. Date
Permit Fee Paid $ Chekki Number (' -�..
Connection Charge Receipt No. qq
Dated
Issued
INSPECTION
Date work started Date completed j'_ -Y-9-3
Sufficient notification`re'ceive : es No
Special Conditions
APPROVED: 3
6a _
Inspector Date
TORN OF SOUTH WIN OR
gr SANITARY SEWER INSPECTION CHECKLIST
• �cc��-CC - -
FUNCTION P NO YES N/A DATE INSPECTED
1. Is Permit On Job Site
2 . Police Notified
3. Safety Items In Place �����
a. Shoring, Trench Box, Ladder
b. Hard Hats
C. Pumps
4. Proper Material
a. Pipe _
b. Pipe Bedding
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 OK
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