HomeMy WebLinkAboutDrain Layers Permit Ellington Ridge/Podu APPLICATION FOR DRAIN LAYER PERMIT
TOWN OF SOUTH WINDSOR4.
$'S
PUBLIC WORKS DEPARTMENT 8�
TOWN HALL
1540 SULLIVAN AVENUE
SOUTH WINDSOR, CT
FEE $60.00
Location of proposed work: �ID C,C _Lot #
Street No. Street Name
Premises owned by: � (L
Name of Firm;_ Phone: c S
Address.of Firm: 411- -r-,
TYPE OF WORK:
Lay House Drain Repair House Drain
Lay Main '
y Lateral for Commercial/Industrial
Building of acres
Connection will be made with A//1
Existing Water Supply: Public Water X Well
Proposed Start Date -I _^- a Estimated time for completion i2(ciii-}
ALL WORK TO BE IN ACCORDANCE WITH TOWN OF SOUTH WINDSOR STANDARDS,
ALL OSHA REQUIREMENTS AND CONDITIONS ATTACHED TO THE PERMIT
Permit is to be issued to _ i tlZ the holder of Drain
Layer's License No. Z.c7"7 Only holders of P-1, P-7 or W-9 licenses
will be issued a permit. 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 attached thereto. Applicant has received
Town Street Excavation Permit No. and/or ConnDOT Permit No.
CBYD No.
{
Signed.
Print Print Name: SCATJ,
Licensed Drain Layer
Date: 'l i—63
Standard Forms\Permits\APPLICATION FOR DRAIN LAYERS PERMIT.doc
TOWN OF SOUTH WINDSOR
NI7ARi SEWER LATERAL FIELD LOCATION
DATE OF CONSTRUCTION:
BUILDING ADDRESS
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CONTRACTOR (PRINT) NAME OF CONTRACTOR'S SUPERVISOR (PRINT)
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STREET ADDRESS SIGNATURE q
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TOWN STATE ZIP INSPECTED BY TOWN
60 DATE
TELEPHONE NUMBER
WHITE - TOWN PINK - CONTRACTOR YELLOW - CONSULTING ENGINEER / DEVELOPER