The private waste disposal application is as follows.
TO THE TOWN OF INDEPENDENCE, VIRGINIA:
The undersigned, being the ____________________________________________ of the property
(owner, owner’s 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 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 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 Section(s)_of the Code of the Town of Independence, Virginia, 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 Health Officer and at no expense to the town.
4. To notify the Superintendent at least 24 hours prior to commencement of the work proposed and again at least 24 hours prior to the covering of any underground portions of the installation.
Date: ___________________ Signed _______________________________________
(applicant)
_______________________________________
(address of applicant)
_______________________________________
(certification by Town Treasurer)
$______________ inspection fee paid
Application approved and permit issued:
Date: ____________________ Signed __________________________
(Superintendent)
(1996 Code, § 128-18)