HomeMy WebLinkAboutDrain Layers Permit 575 Rye Street TOWN OF SOUTH WINDSOR
DEPARTMENT OF PUBLIC WORKS
BUREAU OF POLLUTION CONTROL
DRAIN LAYER'S PERMIT
. � � 19f
Pursuant to written application, permission is hereby granted tot he }'_censed Drain Layer
named herein to perform the work indicated be ow at sy L S /
at premises owned by A�, ,-v"a whose address is
La House Drain and to
Y , Repair House Drain, Lay Main, Other
for ,
occupancy or use, with
Family Units, with / acres.
Type of Sewage to be connected u}nder this permit: SANITARY SEWAGE /), INDUSTRIAL
WASTES ( ), OR ( ) 6 J C/ l 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
F=
� i
Permit to be issued to
the holder of Drain Layer's License No. c"o 7 Permit will expire thirty (30) days
after date of issuance. The undersigned Drain Layer hereby agrees al'� tI4 terms and
conditions set forth in the permit and the reverse side thereof. plic/ant;has received
Town Permit No. and/or CHD Permit No.
Signed ;y J
L cense ��.Layer
The above named Drain Layer has a valid license issued by the Sth-t-e—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—+— `% <<\L' Permit Fee: Paid ` 'C
01 Check Number 'A
Issued by 2C3�'
Tax Office
INSPECTION
Date work started _ Date completed
Sufficient notification red'ei d: _ des No
Special Conditions
APPROVED:
Inspector ate
TOWN OF SOUTH WINDSOR
SANITARY SEWER LATERAL FIELD LOCATION
DATE OF CONSTRUCTION:
BUILDING ADDRESS OR LOT Ng:
STREET: ..:� 75-
SUBDIVISION:
n �+ NH STATION : -I-
NeRTH- -- INVERT ELEV:
'�I E � Shia __'_'_
4rj T I E
-FT �►
-FT
HOUSE LATERAL LATERAL HOUSE
CONNECTION 17 STUB STUB CONNECTION
-FT I 114 46
BUILDING V. ELE ►ritA INV.ELEV. INV. ELEV. INV. ELEV. FT.
(IF EXIST.) �'-roo BUILDING
(IF EXIST.)
TIE TEE
- Mi STATION : +
INVERT ELEV:
v
CONTRACTOR (PRINTF NAME OF CON RA 0 UPER ISOR(PRINT)
�11
STREET ADDRESS F Q6!� SIG TUR DATE
7 �
TOWN STATE ZIP INSPECTED BY TOWN DATE
(d.0,3 )
TELEPHONE NUMBER
WHITE — TOWN PINK -'CONTRACTOR •YELLOW -CON
SUlT11VG ENGINEER/pVELOPER
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