HomeMy WebLinkAboutDrain Layers Permit 115 Rugby Lane 4 TOWN OF SOUTH WI N DSOR
DEPARTMENT OF PUBLIC WORKS
BUREAU OF POLLUTION CONTROL
DRAIN LAYER'S PERMIT '; ^
Pursuant to written application, permission is hereby granted to the Licensed Drain Layer
named herein to perform the work indicated below at / t_5 a 9 /2- u ' 3
at premises owned by 66--'/4 le Cc--;,�s r ' whose address is
7 S' T.r v.«.6 ,r'.:> S o c a= :. ter i•�: ��4 .T
and to
Lay House Drain, Repair House Drain, Lay Main, Other
for ( "-I ) /L y occupancy or use, with
Family Units, with acres.
Type of Sewage to be connected under this permit: SANITARY SEWAGE ik-,-,"INDUSTRIAL
WASTES ( ), OR ( ) Connection will be made with
Show sketch of proposed work or furnish two (2) copies of separate drawings.
9
SPECIAL CONDITIONS /
Desired Starting Date' c4<::� T' a 3 , /y 5Pl Estimated Time for Completion OC2- -7-
Permit to be issued to -j
the holder of Drain Layer's License No. aj 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.
;-
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 Permit Fee: Paid $ 3 - .',0C
Check Number � 11`T
Issued by
Tax Office
INSPECTION f
Date work started Date completed
Sufficient notification received: Yes No
Special Conditions
APPROVED:
Inspector Date
r
TOWN OF SOUTH WINDSOR
SANITARY SEWER LATERAL FIELD LOCATION
DATE OF CONSTRUCTION: // S�
BUILDING ADDRESS OR LOT N' :
STREET: f u
SUBDIVISION: `Lr
thi STATION : +
NORTH ARROW INVERT ELEV:
TIE TIE
FT -FT.
tlp
HOUSE LATERAL LATERAL HOUSE
CONNECTIONO STUB STUB CONNECTION
FT. FT.
BUILDING INV. ELEV. INV.ELEV. INV. ELEV. INV. ELEV. BUILDING
(IF EXIST.) (IF EXIST.)
TIE TIE
NH STATION : +
INVERT ELEV:
Bdl kQau& s
CONTRACTOR (PRINT) NAME OF CONTRACTORS SUPERVISOR(PRINT)
12,4
STREET.ADDRESS SIGNATURE DATE
F
TOWN STATE ZIP INSPECTED BY TOWN AT
( ;?,0-;) C� �
TELEPHONE NUMBER
WHITE - TOWN PINK - CONTRACTOR YELLOW -CONSULTING ENGINEER/DEVELOPER