HomeMy WebLinkAboutdrain layer permit 180 Sullivan Avenue TOWN OF SOUTH WI N DSOR
DEPARTMENT OF PUBLIC WORKS
BUREAU OF POLLUTION CONTROL
DRAIN LAYER'S PERMIT
19_
Pursuant to written application, permission is hereby granted ;to the Licensed Drain Layer
named herein to perform the work indicated below at I- c) ^�r/
at premises owned by f whose address is
P% and to
Lay House Drain, Repair House Drain, Lay Main, Other
for occupancy or use, with
Family Units, with acres. -; 71-1 �;E'A
Type of Sewage to be connected under this permit: SANITARY SEWAGE ( ), INDUSTRIAL
WASTES ( ), OR { ) �� i r,��r �',.�,�,G. Connection will be made with
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Show skALch of op fu ish two (2) copies of separate drawings.
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SPECIAL CONDITIONS
Desired Starting Date- ? - Estimated Time for Completion
Permit to be issued to )`'`t h r4
the holder of Drain Layer's License No. __"c3 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/ CHHDD Permit No.
Signed
vG / 26-g r 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:
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Engineering Department Date
Connection Charge Paid \' � �_ '� Permit Fee: Paid $
Check Number t`
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Issued by
Tax Office
INSPECTION c
Date work started �✓ Z g/ Date completed 6 ` Z d > / 1
Sufficient notification received: t/ Ye's No
Special Conditions
APPROVED:
Inspector Dat
PMT-1 Rev. 11/88
Application form must be
lz_ State of Connecticut _
May 22, 1991 — Department of Transportation filled in completer•and
Fee:(fa DOT use) mailed or delivered tU the
APPLICATION FOR PERMIT Bureau of Highways District Office.
LOCATION OF PROPOSED WORK:
(a) Town: South Wi nd-sor _ (b)- Route: 194 (c) Street Name&No. 180 Sullivan Avenue
(d) (Circle One)N. S. E. W. side of Highway. (e) Located Between Utility Poles No. 1472 &No. _ 11173
corner of Rt 194
(f) Distance and direction from nearest intersecting road. and—R-ye --St Miles(N. S. E. W.)of Rye Stree is _ _(St/Rd)
,/Application is hereby made to:(Desc•rihe fully& inc•lucle sketch or attach plans) hook up t0 City sewer
see attached plan
i't'"
,�3&-I/
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Department of Trani •1.0--ation
District #1 Office
1107 Cromwell Avenn•
Rocky Hill, Corjjv: i • iiyl. 06067
PERMIT FEE can be paid only by check or money order payable to Treasurer-State of Conn.
Name of Surety Company&amount of Bond Permit to be issued to: ^
Party to whom Bond is issued: Name Shell Oil Company__..
visrint Name S O i 1 mpany &
vSigned �._ Phone 678-7008 Address 22 hrdtervi 11 r� Road
Party 51 hom Insurance is issued: Town Avon, CT
11 06001
Print Name M & A Construction The owner of the property for whom this work is being performed
agrees to accept all future maintenance responsibility Inr the work
(signed AZZZ2,1, ��J7p Phone 677-7256 specified in the permit.
Approximate Time Required Desired Starting Date YPrint Owner's Name pany
pp l g Shell Oil Com
2 weeks 5/27/91
Address 22 ry i 1 Ro , Avon, CT 06001
Complete+'Plans and Specifications must be submitted for major
`ncroach»ient permits.On other work a careful sketch shall be shown `Signed Phone (i78-70Q8
space above or on back side of application. i m 1 a — —
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