HomeMy WebLinkAboutDrain Layers Permits 245 Pepin Place (2) 1800092
PERMIT NUMBER TOWN OF SOUTH W I N D S O R, CT
DRAIN LAYER PERMIT
DATE: 12/Q7/2018 y�`' �`�
GIS ID: 70700245
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MUNIS APPLICATION# 201802358
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Y FEE:
APPLICANT EXPIRATION 0.00
NAME: ATLANTIC y S t s� DATE: 01/06/2019
EXCAVATI #s s{ ` 4 r' ``tx` S y ;� OCATION
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ADDRESS: 363 PARUM ROAD Q` fK y Fi ' RES yti L r24 pE PLACE
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THE DRAIN LAYER ASSIGNED TO THIS PSG ry � 201$07 4y, 1 yAF
THE TERMS AND CONDITIONS SET FORTIS 7 a I SAS A V IDaI .pSUJ?D'By-Tr k
THE TOWN OF SOUTH WINDSOR STANDARD&
, STATE AND HEREBY AGREES TO ALL
TACHED ` 1fII II tNS � 'SHALL BE IN ACCORDANCE WITH
��L aS�A,REQU MENTS,AND T ` gCHED CONDITIONS.
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INSPECTED BY
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APPLICATION FOR DRAIN LAYER PERMIT
TOWN OF SOUTH WINDSOR
PUBLIC WORKS DEPARTMENT
TOWN HALL
1540 SULLIVAN AVENUE
BLS,. SOUTH WINDSOR, CT
' FEE $80.00
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Location of proposed work: 5 n, `r- Lot #
Street No. Street Name
Premises owned by:
Name of Firm: Z c c n Phone: W -
Address of Firm:
TYPE OF WORK: /
Lay House Drain P; Repair House Drain ; Sanitary Disconnect
Lay Lateral for building with connection or no connection ;
Lay Main ..
Lay Lateral for Commercial/Industrial Building number of acres
Connection will be made with ,tS7l�i�f 5 ;�?Pe—
Existing Water Supply: Public Water Well
Proposed Start Date 6 Estimated time for completion
ALL WORK TO BE IN ACCORDANCE WITH TOWN OF SOUTH WINDSOR STANDARDS,
ALL OSHA REQUIREMENTS AND CONDITIONS ATTACHED TO THE PERMIT
Permit is to. � �be issued to , 7 - the holder of Drain
Layer's License No.c*n ?7 Only holders of P-1, F-7 or W-9 licenses
will be issued a permit. PERMIT WILL EXPIRE THIRTY(30) DAYS AFTER
DATE OF ISSUANCE. The undersigned Drain Layer hereby agrees to all the terms
and conditions set forth in the permit and attached thereto. Applicant has received
Town Street Excavation Permit No. and/or ConnDOT Permit No.
CBYD No. x'61$ L22 r 7z92 PLEASE NOTE:
IF A sANITARY SEWER LATERAL
IS WITHIN 75 FEET OF A WELL
IT MUST BE-AIR TESTED .
Signed Print Name:_5; i/ems
Licensed Drain La 3
Date: 6 l'
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Standard Forms\PermiWPPLICA17ON FOR DRAIN LAYERS PERMIT REVISION 3/2018.doc
TOWN OF SOUTH WINDSOR
SANITARY SEWER LATERAL FIELD LOCATION
DATE OF CONSTRUCTION: V,-
BUILDING ADDRESS Zh 3 ZL! G q
STREET : � ''v�
SUBDIVISION: ,) c
NORTH ARROW177.
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CONTRACTOR (PRINT) NAM -OF-CO TRACTOR' SUPERVISOR (PRINT)
STREET ADDRESS SI ATURE -
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TOW�Ny, STATE ZIP INSPECTED BY TOWN
U�� •��� ������ , _ DATE
TELEPHONE NUMBER
WHITE - TOWN PINK - CONTRACTOR YELLOW - CONSULTING ENGINEER / DEVELOPER