HomeMy WebLinkAboutDrain Layers Permits 116 Pepin Place APPLICATION FOR DRAIN LAYER PERMIT
TOWN OF SOUTH WINDSOR
PUBLIC WORKS DEPARTMENT
TOWN HALL
1540 SULLIVAN AVENUE
SOUTH WINDSOR, CT
vl&Ce o ti c9 i,5- 9 t) FEE $80.00
Location of proposed work: A ---/; z=� ,e Az.a Lot #
Street No. S reet Name
Premises owned by: ,-"- :` c c
Name of Firm: ,tee� c Phone: 3 ��
Address of Firm:
TYPE OF WORK:
Lay House Drain ; Repair House Dra' ;
Lay Lateral for building with connection , or no connection ;
Lay Main
Lay Lateral for Commercial/Industrial Building number of acres
Connection Will be made with = Y
Existing Water Supply: Public Water Well
Proposed Start Date 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 the holder of Drain
Layer's License No. Only holders of P-1, P-7 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. ®��f'�3�b3�` �� _ PLEASE NOTE:
IF A SANITARY SEWER LATERAL
IS WITHIN 75. FEET OF A WELL
IT MUST BE AIR TESTED
7
Sign Print Name: �� ,�
Licensed Dr Layer
Date:
Standard Forms\Permits\APPLICATION FOR DRAIN LAYERS PERMIT REVISION 2017.doc
TOWN OF SOUTH WINDSOR
SANITARY SEWER LATERAL FIELD LOCATION
DATE OF CONSTRUCTION: �® 117 _
BUILDING ADDRESS �-
STREET : Pik-
SUBDIVISION:
NORTH ARROW
of
7t
f
CONTRACTOR (PRINT) NAME
,OF�CONTRACTOR'S SUPERVISOR (PRINT)
STREET ADDRESS. SIGNATURE
fie Z--/.�c-/- pit 44,
DATE
TOWN STATE ZIP INSi ED BY TOWN
9, DATE
TELEPHONE NUMBER
WHITE — TOWN PINK — CONTRACTOR YELLOW - CONSULTING ENGINEER / DEVELOPER