The application and permit for water and/or sewer connection in the town is as follows.
APPLICATION FOR WATER AND/OR SEWER CONNECTION
IN THE TOWN OF INDEPENDENCE
The undersigned hereby makes application for a water and/or sewer connection to the water and/or sewer system(s) in the Town of Independence.
Location: ________________________________________________________________________
Description of property: _____________________________________________________________
Type of connection requested:
Single dwelling ____, Multiple dwelling _____, Trailer or mobile home _______,
Business ____, Industry ____, Other (please specify) ____,
Sewer Connection $_______
Water Connection $_______
Date __________________________ __________________________________
Signature of Applicant
PERMIT FOR SEWER CONNECTION OR WATER CONNECTION
FOR THE TOWN OF INDEPENDENCE
ISSUED TO: ______________________:
Subject to compliance with the town ordinances, you are permitted to connect to and use the water and/or sewer system of the Town of Independence.
Receipt of $_____ for connection fee (water) is acknowledged.
Receipt of $_____ for connection fee (sewer) is acknowledged.
Date _______________
TOWN OF INDEPENDENCE, VIRGINIA
BY: ___________________
This permit covers the following described connection: ___________________________________
________________________________________________________________________________
________________________________________________________________________________
SIGNATURE (authorized representative of the town) ____________________________________
Date: ______________
(1996 Code, § 128-30)