HomeMy WebLinkAboutDrain Layers Permit 43 Shares Lane �` 'Y"�.,iw3 ���,R.' C�l'c+ - ✓ S.±�c., 4,r" '.}sF�4F'.".r. n.. .,r
6362
TOWN Of SOUTH WINDSOR
DEPARTMENT OF PUBLIC WORKS
BUREAU.OF POLLUTION CONTROL
r
_DRAIN LAYER'S PERMIT
DATE:_ � S—
Pursuant to written applicati n, permissio is hereby granted to the Licensed Drain Layer named herein to
perform work at e Lot#�as indicated belor}y it
premises owned b /h,�I�t' . Sty$..whose address is
to Lay House Drain Repair House Drain Lay Main , Other , for
occupancy oruse, with acres.
Type of Sewage to be connected under this permit: SANITARY SEWAGE. MO&USTRIA ky STES(J,
OR f J Connection wil/be made with r - . All
work to be.in accordance with 70A,� of South Windsor standards, all OSHA-requirements and the cond/tians
indicated on the back of this pe it.
Proposed start date Estimated time for completion , e vo4,
Permit is'to be issued to f✓� i�,rfl�= (,�/J� l the holder of Drain Layer's License No.
Only holders of P1, P7 & W9 licenses .will be issued permit. Permit will ex
dire thirty 13Q1
days after date of issuance. The undersigned Drain Layer hereby agrees to all the terms and conditions set
forth i �andlor
permit and the reverse side thereof. Applicant hasiyed Town S ee Ex vatio ermit No.
ConnDOTPermit No. �..
Signed
Licensed rain Layer
FOR TOWN USE ONLY
Permit Fee Paid$ 95-Oy (Check No.) 296 9
Y N Connection Charge $ (9M.00 (Receipt No.) Dated I t-aa�g
Insurance on File (vr( J
Bond on File ( ( 1 This petit is hereby issued to the above named Drain Layer who has a valid
license issued by the State of Cbmwdeut and has on Me,satisfactory bond
Premises subject to and insurance in the name of the Town of South Windsor.
Intertown Agreement ( l
Record of Sewer
Assessment 4-U-4 Issued by f � 1 ��,,r „ Date
INSPECTION
Date Work Started Date Completed
Comments
APPROVED:
Inspector Date
SANITARY. LATERAL-,&. EXCAVATION PERMIT-
INSPECTION REQUEST
DATE OE`.;REQUEST j/ - 5� TIME: f
FOR LOCATION:
DAY INSPEC. NEEDED Z/ -}5 TIME: 4i9-77,f
TYPE "OF `INSPECTION:
t SArIITARY/LATER LC (-FERMTT','-N0}.: F00T.ING .:DRAIN
R ( ) EXCAVATION (PERMIT NO: ) ( ) OTHER
` lHS,P,E0TL0N ,REP0FtT
DATES //� 2/- TIME: INSP:
r - < CONTRACTM..::. rili/��cv WEATHER' c� L
.. WORK IN PROGRESS:
AREA OF CONCERN:
SPECIAL INSTRUCTIONS: