HomeMy WebLinkAbout236 Fairview Dr - Application & Tie CardAPPLICATION 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: L Q O I C-W b 2 Lot #
Street No Street Name
Premises owned by:
So
U ti M Ii (I t"I
Name of Firm: (7n._) I) i Q 6LA)ly' I 1 c � I �'(Phone: Lb Q Coo
Address of Firm:
TYPE OF WORK:
Lay House Drain ; Repair House Drain ;
Lay Lateral f r building with connection ; or no connection ;
Lay Main rK
Lay Lateral for Commercial/Industrial Building number of acres
Connection will be made with F Ey�
Existing Water Supply: Public Water Well
Proposed Start Date 3 Estimated time for completion 7 '
ALL WORK TO BE IN A CO DANCE WITH TOWN OF SOUTH WINDS R SANDARDS,
ALL OSHA REQUIREMENT AND CONDITIONS ATTACHED TO THE PERM
Permit is to be issued to M I �C f` a J CA) S 6 the holder of Drain
Layer's License No. ,Lo") QQL . Only h, Iders 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.do)-3 �5'02- 1 1
Signed:
Layer
PLEASE NOTE:
IF A SANITARY SEWER LATERAL
IS WITHIN 75 FEET OF A WELL
IT MUST BE AIR TESTED
Print Name: A p1 ` poo1c, 4S
Standard Forms\P�rmitS\APPLI�ATION FOR DRAIN LAYERS PERMIT REVISION 2017.doc
TOWN OF SOUTH WINDSOR
SANITARY SEWER LATERAL FIELD LOCATION
DATE OF CONSTRUCTION:
BUILDING ADDRESS
STREET
SUBDIVISION:
7/19-/aaa3
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TELEPHONE NUMBER
SIGNA1URIL,
INSPECTED BY TOWN
DATE
WHITE — TOWN PINK — CONTRACTOR YELLOW — CONSULTING ENGINEER / DEVELOPER