Application for Sewer Connection Permit
Date _________________
1. Name
2. Address
3. Premises for which permit is requested
4. Number of located in premises _________________
5. Sewer rental bills should be sent to
6. Date on which notice to connect was received
7. Amount enclosed $
Action Taken on Above Application
Permit number ___________ was issued to applicant on ___________________, 19_____, and the permit fee in the amount of $___________ has been received. The connection was completed and inspected on ___________________, 19_____.
Chairman, Sewer Committee
or his appointed substitute
Sewer Connection Permit
Permit Number
Issued to
For Premises Located at
Dauphin, Pennsylvania
Permit Fee $
This permit entitles the above-named person to connect the above described premises to the Borough’s sewer system in accordance with the General Sewer Ordinance, dated February 28, 1961, as amended, and the rules and regulations of the Borough of Dauphin.
Issued this _________________ day of __________________, 19_____.
Borough of Dauphin
By __________________________
Chairman, Sewer Committee or his appointed substitute