§ 1. PRIVATE WASTE DISPOSAL APPLICATION.

To the Municipality of Dublin, Ohio:

   The undersigned, being the                                                         of the property located at (owner, owner's agent)

                                                                                                does hereby request a

(number) (street)

permit to install sanitary sewage disposal facilities to serve the

(residence, commercial building, etc.)

at the location.

   1.   The proposed facilities include: ___________________________
_________________________________________________________________

to be constructed in complete accordance with the plans and specifications attached hereunto as Exhibit "A".

   2.   The area of the property is                   square feet (or square meters).

   3.   The name and address of the person or firm who will perform the work is ____________________________________________________

   4.   The maximum number of persons to be served by the proposed facilities is __________________________________

   5.   The locations and nature of all sources of private or public water supply within one hundred (100) feet (30.5 meters) of any boundary of said property are shown on the plat attached hereunto as Exhibit "B".

   In consideration of the granting of this permit, the undersigned agrees:

   1.   To furnish any additional information relating to the proposed work that shall be requested by the superintendent.

   2.   To accept and abide by all provisions of Ordinance No. 59-74 of the Municipality of Dublin, Ohio, and of all other pertinent ordinance or regulations that may be adopted in the future.

   3.   To operate and maintain the wastewater disposal facilities covered by this application in a sanitary manner at all times, in compliance with all requirements of the Franklin County Health Department and the Ohio Environmental Protection Agency, and at no expense to the Municipality.

   4.   To notify the superintendent at least twenty-four (24) hours prior to commencement for the work proposed, and again at least twenty-four (24) hours prior to the covering of any underground portions of the installation.

   

Date: ______________    Signed ___________________________

               (applicant)

$                              inspection fee paid.   _________________________

Application approved and permit issued:    (address of applicant)

Date: ___________________      _____________________________
                  (certification by Clerk)

      Signed __________________________

         (Superintendent)

('80 Code, Ch. 921, Appendix A) (Ord. 59-74, passed 11-18-74)