913.271A SEWER TAP-IN APPLICATION FORM.
 
DEPARTMENT OF PUBLIC SERVICE
Division of Engineering
 
DISTRICT STORM DRAINAGE SEWER PERMIT NO.   VOID 1 YEAR FROM DATE
DISTRICT                           
 
Permission is hereby granted to                                                                  to connect
premises located at Lot               Blk.                 Addition                                                    
with the main Sewer located in                                                 Street, said applicant in
accepting this permit agrees in consideration of the rights and privileges granted:
   (1)    To hold the City harmless for any loss or damage that may in any way result from or be occasioned by such connection:
   (2)    That said owner shall maintain said connection or sewer in a serviceable condition from the building to the Tee, 'Y', or Tap in the main sewer, all at his own cost and expense:
   (3)    That any part where deemed in public interest, be appropriated by the City as a public sewer;
   (4)    That the use and construction of said connection or sewer shall be subject to and in conformance with all regulations and conditions set forth in City Ordinances controlling the use and construction of District Area Storm Drainage facilities.
 
Permit charges due and payable prior to issuance of permit:
   Sewer Permit Fee                                                  
   Tap-In and Service Charge                                     (Calculations on reverse side)
   Deferred Assessment Charge                                  (Calculations on reverse side)
   Pavement Opening Deposit                                Permit Issued on               ,198     
                      Deposit Refunded             ,198    
   Other Charges                                                       (See reverse side)
 
   TOTAL CHARGES                                               
 
Licensed Sewer Contractor (authorized by the Owner)                                                         
                      (Licensed Contractor)
Permit Issued                                             
 
Date                                                          
 
Signed                                                       
       (City Engineer)
 
Copy forwarded to the Director of Utilities                                                                         
                        (Date)
 
(Ord. 19-91. Passed 3-18-91.)