To the City of Grayville:
A. THE UNDERSIGNED, being the property located
(Owner, Owner's Agent)
at DOES HEREBY REQUEST a
Number Street
permit to install and connect a building to serve the at the location.
(Residence)
1. The following indicated fixtures will be connected to the proposed building sewer:
Number Fixtures Number Fixtures
Kitchen Sinks Water Closets
Lavatories Bath Tubs
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”.
B. In consideration of the granting of this permit, THE UNDERSIGNED AGREES:
1. To accept and abide by all provisions of the City Code of the City of Grayville, 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 city.
3. To notify the Grayville City Council 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)
(Certification by Treasurer)
$ connection fee paid.
$ inspection fee paid.
Application approved and permit issued:
DATE: SIGNED:
(Approving Authority)