HomeMy WebLinkAboutDrain Layers Permits 112 Pepin Place APPLICATION FOR DRAIN LAYER PERMIT
TOWN OF SOUTH WINDSOR
PUBLIC WORKS DEPARTMENT
TOWN HALL
1540 SULLIVAN AVENUE
uvk6U,t )C r`'7 0 i S'� � SOUTH WINDSOR, CT
FEE $80.00
Location of proposed work: — Lot #
Street No. S reet name
Premises owned by:
Name of Firm: Phone: -onA-0-//
Address of Firm:
TYPE OF WORK:
Lay House Drain ; Repair House Drain ;
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 fDR .�S-
Existing Water Supply: Public Water I '� 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 Z�; . the holder of Drain
Layers 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 he 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. �1,7 f.3cD3C 9,9� PLEASE NOTE:
IF A SANITARY SEWER LATERAL
IS WITHIN 75 FEET OF A WELL
IT MUST BE AIR TESTED
Sign "7 Print Name:
Licensed Dr ` Layer
Date:
Standard Forms\Permlts\APPLICATION FOR DRAIN LAYERS PERMIT REVISION 2017.doc
TOWN OF SOUTH WINDSOR
SANITARY SEWER LATERAL FIELD LOCATION
DATE OF CONSTRUCTION: 7 ._.�
BUILDING ADDRESS acz
STREET : m PoLL
SUBDIVISION: ® f C
NORTH ARROW
/45
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43
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417,
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CONTRACTOR (PRINT) . NAME OF CONTRACTOR'S SUPERVISOR PRINT)
STREET ADDRESS SIGNATURE
,n /L57Z- '� of�)C Y/3- pletelvz 11- 2 47 DATE
TOWN STATE ZIP INS f ED BY TOWN
Ck o. :A3, _ DATE
TELEPHONE NUMBER
WHITE - TOWN PINK - CONTRACTOR YELLOW - CONSULTING ENGINEER / DEVELOPER