HomeMy WebLinkAboutDrain Layers Permits 5 Grace Road 1600095 TOWN OF SOUTH WINDSOR, CT
PERMIT NUMBER DRAIN LAYER PERMIT
DATE: 12/20/2016 t,
GIS ID:37200005 4 ' 1 FEE: 60.00
MUNIS APPLICATION# 201601851 EXPIRATION DATE: 01/19/20I7
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APPLICAN �� 5 a ti
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LOCATION
NAME: WASTEWATER SEWqE$J'. BA SIPS 4 DDRI~SS _ 4 5� RA{ E ROAD
ADDRESS: 21 GOURTNEY DRt`Vl :t t, 4 C)WNLR ' ULT()N JAMES D&NANCY P
ELLINGTON,CT 0�5029 GTiA E ROAD
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r $\SJrJTWINDSOR, CT 06074
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WORK DESCRIPTION: NEW AwLR CQ
THE DRAIN LAYER ASSIGNED TO THI PE12> IIT H IS!"U I l,1f ENS `ISSUED BY''I°H STATE AND HEREBY AGREES TO ALL
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THE TERMS AND CONDITIONS SET FOl$ H ZN TTACI y3710-1ITTOIS� �E V�ORK SHALL BE IN ACCORDANCE WITH
THE TOWN OF SOUTH WINDSOR STANDAtDS ALL OSHA R �IJYREMET�,AI3IE ATTACHED CONDITIONS.
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ISSUED BY DATE MPECTED INSPECT B
12/20/2016 10:39 AM
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TOWN OF SOUTH WINDSOR INSPECTION REPORT
PERMIT NO.: CONTRACTOR: S
LOCATION:
TYPE OF WORK: IUD . -
DATE INSP NEEDED: DATE INSP 6 C
INSPECTED BY: jz
WORK IN
PROGRESS: S
SEPTIC TANK PUMPS , SMASHED, FILLED WITNESSED YES ❑ NO
AS-BUILT:
INPUT: DATE: t
S/FORMS/TOWN.OF SOUTH WINDSOR INSPECTION
APPLICATION FOR DRAIN LAYER PERMIT
TOWN OF SOUTH WINDSOR
PUBLIC WORKS DEPARTMENT
TOWN HALL
1540 SULLIVAN AVENUE
SOUTH WINDSOR, CT
FEE $60.00
Location of proposed work: S GrF-19cC 7��( Lot #
Street No. Street Name
Premises owned by:__Ju-D1 rN Co9�z uSo "36o^-Zo 4--. �S ��--
Name of Firm: Shins Phone:
Address of Firm: Z� '�� �'y — 'ELIL/N 6-/'o vl
TYPE OF WORK:
Lay House Drain ; Repair House Drain ;
Lay Main ; Lay Lateral for Commercial/Industrial
Building of acres
Connection will be made with
Existing Water Supply: Public Water Well X
Proposed Start Date w�,,-/r ho� Estimated time for completion
ALL WORK TO BE IN ACCORDANCE WITH TOWN OF SOUTH WINDSOR STANDARDS,
ALL OSHA REQUIREMENTS AND CONDITIONS ATTACHED TO THE PERMIT
Permit is to be issued to —rd'yk ��� the holder of Drain
Layer's License No. o z o 17172-Y . Only holders of P-iCP or W-9 licenses
will be issued a permit. 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 attached thereto. Applicant has received
Town Street Excavation Permit No. and/or ConnDOT Permit No.
CBYD No. �1� S_10 a/,6 � PLEASE NOTE:
IF A SANITARY SEWER LATERAL
IS WITHIN 75 FEET OF A WELL
IT MUST BE AIR TESTED
Signed: 24=� Print Name:''?
Licensed Drain Layer
Date: 17- -z c- 16
Standard Fcrms\Permits\APPLICATION FOR DRAIN LAYERS PERMIT.doc
TOWN OF SOUTH WINDSOR
SANITARY SEWER LATERAL FIELD LOCATION
DATE OF CONSTRUCTION: L-Z Z'
BUILDING ADDRESS Gf �
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SUBDIVISION:
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CONTRACTOR (PRINT) NAME F CONTRACTOR'S SUPERVISOR (PRINT)
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STREET ADDRESS j SIGNATURE
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TOWN STATE ZIP INSPECTED BY TOWN
DATE
TELEPHONE NUMBER
WHITE — TOWN PINK — CONTRACTOR YELLOW CONSULTING ENGINEER / DEVELOPER