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TOWN OF SOUTH WI N DSOR
DEPARTMENT OF PUBLIC WORKS
BUREAU OF POLLUTION CONTROL
DRAIN LAYER'S PERMIT �. 4769
19 7
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Pursuant to written application, permission is hereby gra)ited tb the Licensed Drain Layer
named herein to perform the work indicated below at "
at premises owned by �:: �, cam. :. 1ie� whose address is
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. p�S',-� C_ . 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
icensed Drain LkVer
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 Departmoe Date
Connection Charge Paid C�D (/ Permit Fee: Paid $
-- . Check Number V
ilt,� ��{_v ,�.( Issued by
Tax Office
INSPECTION
Date work started Date completed
Sufficient notification received: Yes No
Special Conditions
APPROVED:
Inspector pate