To the Municipality of Dublin, Ohio:
The undersigned, being the _______________________________ of
(owner, owner's agent)
the property located at ____________________________________ does
(number) (street)
hereby request a permit to install and connect a building sewer to serve the ____________________________________ at said location.
(residence, commercial building, etc.)
1. The following indicated fixtures will be connected to the proposed building sewer:
Number Fixture Number Fixture
______ Kitchen sinks ______ Water closets
______ Lavatories ______ Bathtubs
______ Laundry tubs ______ Showers
______ Urinals ______ Garbage grinders
Specify other fixtures ________________________________________
2. The maximum number of persons who will use the above fixtures is .
3. The name and address of the person or firm who will perform the proposed work is _________________________________________________
4. Plans and specifications for the proposed building sewer are attached hereunto as Exhibit "A".
In consideration of the granting of this permit the undersigned agrees:
1. To accept and abide by all provisions of Ordinance No. 59-74 of the Municipality of Dublin, Ohio, and of all other pertinent ordinances or regulations that may be adopted in the future.
2. To maintain the building sewer at no expense to the Municipality.
3. To notify the superintendent when the building sewer is ready for inspection and connection to the public sewer, but before any portion of the work is covered.
Date: ______________ Signed ___________________________
(applicant)
________________________
(address of applicant)
Applicant approved: ________________________
Applicant approved: ________________________
Date: ___________________ _____________________________
(certification by Clerk)
(certification by Clerk)
Signed __________________________
(Superintendent)
('80 Code, Ch. 921, Appendix B) (Ord. 59-74, passed 11-18-74)