To the City of Grayville:
A. THE UNDERSIGNED, being the of the property
(Owner, Owners Agent)
located at .
Number Street
DOES HEREBY REQUEST a permit to install sanitary sewage disposal facilities to serve the at the location.
(Residence, Commercial Building, etc.)
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 to be served by the proposed facilities 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 the 100 feet (30.5 meters) of any boundary of said property are shown on the plat attached hereunto as Exhibit “B”.
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 Grayville City Council.
2. 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.
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 city and at no expense to the city.
4. To notify the at least 24 hours prior to commencement of the work
(Approving Authority)
proposed, and again at least 24 hours prior to the covering of any underground portions of the installation.
DATE: SIGNED:
(Applicant)
(Address of Applicant)
$ inspection fee paid.
(Certification by City Treasurer)
Application approved and permit issued:
DATE: SIGNED:
(Approving Authority)