HomeMy WebLinkAboutDrain Layers Permits 241 Pepin Place 1800091 TOWN OF SOUTH WINDSOR, CT
PERMIT NUMBER DRAIN LAYER PERMIT
DATE: 12/07/2018
GIS ID:70700241 {r � `�� FEE: 80.00
MUNIS APPLICATION# 201802357EXPIRATION DATE: 01/06/2019
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APPLICANT 5 K x y$ Fa<z r i °` �� �A OCATION
NAME: ATLANTIC EXCAVATE kM1 , ���'y` � �t' 2 r}t,�D SS, ` 24�1 P k PLACE
ADDRESS: 363'PARUM ROAD ti y rM�UILDING CO INC
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COLCHESTER,CT 06415 i
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WORK DESCRIPTION: NEW SEW&MOI"MM-p 'ICN"P Z p I X7Il`JG 5 241 2 5,2 253 257 8c
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THE DRAIN LAYER ASSIGNED TO THIS P I rS A Vt1TD LI+ NsIy)51 D BY T�IB STATE AND HEREBY AGREES TO ALL
THE TERMS AND CONDITIONS SET FORTI II IIE �TACHED s p1 R TIONS' ALI; SHALL BE IN ACCORDANCE WITH
THE TOWN OF SOUTH WINDSOR STANDARM"li � A:REQUIkIGI+IENTS,A13D TIIACHED CONDITIONS.
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' TOW:D OF SOUTH WINDSOR INSPECON REPORT
PERMIT NO.: " CONTRACTOR:
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TYPE CF WORK: " :o to L�2
DATE INSP IVEEQEI : DATE
INSPECTED By!..: :`B.D
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APPLICATION FOR DRAIN LAYER PERMIT
TOWN OF SOUTH WINDSOR
PUBLIC WORKS DEPARTMENT
TOWN HALL
1540 SULLIVAN AVENUE
SOUTH WINDSOR, CT
FEE $80.00
Location of proposed work: ` Lot #
Street No. Street Name
Premises owned by: r .
Name of Firm: Z 'f jt Phone: W6
Address of Firm: � ru� c �/ w-
TYPE OF WORK: /
Lay House Drain ill ; 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
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 �,'� _c C��'t the holder of Drain
Layer's License No.Cl,!n�,p •P. Only holders of P-1, 0-7 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. a�G/_� f' / ��� PLEASE NOTE:
IF A SANITARY SEWER LATERAL
IS WITHIN 7S FEET OF A WELL
IT MUST BE-AIR TESTED .
Signed Print Name:
Licensed Drain La
Date: 0 l°
Standard Forms\PermitskAPPLICATION FOR DRAIN LAYERS PERMIT REVISION 3/2018.doc
TOWN OF SOUTH WINDSOR
SANITARY SEWER LATERAL FIELD LOCATION
DATE OF CONSTRUCTION: V,— _..._
BUILDING ADDRESS
STREET
SUBDIVISION: Q��5- 3
NORTH ARROW
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CONTRACTOR PRINT) NAM 0 TRACTOR' SUPERVISOR (PRINT)
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STREET ADDRESS ,r SI ATURE
TOWN �f STATE ZIP INSPECTED BY TOWN
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TELEPHONE NUMBER
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