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TOWN OF SOUTH WI N DSOR
DEPARTMENT OF PUBLIC WORKS
BUREAU OF POLLUTION CONTROL
DRAIN LAYER'S PERMIT NNO, 4765
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Pursuant to written application, permission is hereby granted to the Licensed Drain Layer
named herein to perform,,the wgrk indicated below at
at remises owned b
P Y 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 — Permit will expire thirty (3,0) days
after date of issuance. The undersigned Drain 1ayer 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 01
icensed Drain aver
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:
Engi Bring Department Date
Connection Charge Paid U Permit Fee: Paid $ �J, QU
Check Number
Issued by
Tax Office
INSPECTION
Date work started Date completed
Sufficient notification received: Yes No
Special Conditions
APPROVED:
Inspector Date