APPENDIX #3. SEWER CONNECTION APPLICATION.

   RESIDENTIAL OR COMMERCIAL BUILDING SEWER APPLICATION

   The undersigned, being the (owners, owner’s agent) of the property located at (number) (street) does hereby request a permit to install and connect a building sewer to serve the (residence, commercial building and the like) at said location.

   1.   The following indicated fixtures will be connected to the proposed building sewer:

 

Number	Fixture	Number	Fixture
	Kitchen Sinks		Water Closets
	Lavatories		Bathtubs
	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 sewers are attached hereunto as Exhibit “A”.

IN CONSIDERATION OF THE GRANTING OF THIS PERMIT, THE UNDERSIGNED AGREES:

   1.   To accept and abide by all the provisions of the Revised Code and all other pertinent ordinances and codes that may be adopted in the future.

   2.   To maintain the building sewer at no expense to the village.

   3.   To notify the village and SCWRD when the building sewer is ready for inspection and connection to the public sewer, but before any portion of the work is covered.

DATE: ______________________, 20_______   SIGNED: __________________________________

                        (APPLICANT)

                        __________________________________

                        (ADDRESS OF APPLICANT)

   (CERTIFICATION BY CLERK)

$____________   (Inspection fee paid)         DATE: _______________________, 20_______

$____________   (Connection fee paid)      SIGNED: _______________________________

                                          (CLERK)

   (APPLICATION APPROVED AND PERMIT ISSUED)

DATE: __________, 20_____   SIGNED: _____________________________________________

                  (PUBLIC WORKS DIRECTOR OR SUPERINTENDENT)

   INDUSTRIAL SEWER CONNECTION APPLICATION

   The undersigned, being the (owners, owner’s agent) of the property located at (number) (street) does hereby request a permit to (install, use) an industrial sewer connection serving the                           , which company is engaged in __________________ at said location.

   1.   A plan of the property showing accurately all sewer and drains now existing is attached hereunto as Exhibit “A”.

   2.   Plans and specifications covering any work proposed to be performed under this permit is attached hereunto as Exhibit “B”.

   3.   A complete schedule of all process waters and industrial wastes produced or expected to be produced at said property, including a description of the character of each waste, the daily volume and maximum rates of discharge and representative analyses is attached hereunto as Exhibit “C”.

   4.   The name and address of the person or firm who will perform the work covered by this permit is _______________________________________________________________________.

IN CONSIDERATION OF THE GRANTING OF THIS PERMIT, THE UNDERSIGNED AGREES:

   1.   To furnish any additional information relating to the installation or use of the industrial sewer for which this permit is sought as may be requested by the village.

   2.   To accept and abide by all the provisions of the Revised Code and all other pertinent ordinances and codes that may be adopted in the future.

   3.   To operate and maintain a control manhole and any waste pretreatment facilities, as may be required as a condition of the acceptance into the public sewer of the industrial wastes involved in an efficient manner at all times, and at no expense to the village.

   4.   To cooperate at all times with the village and its representative(s) in their inspecting, sampling, and study of the industrial wastes, and any facilities provided for pretreatment.

   5.   To notify the village immediately in the event of any accident, negligence, or other occurrence that occasions discharge to the public sewers of any wastes or process waters not covered by this permit.

   6.   Notify village and SCWRD for service inspection.

DATE: ______________________, 20_______   SIGNED: __________________________________

                        (APPLICANT)

                        __________________________________

                        (ADDRESS OF APPLICANT)

   (CERTIFICATION BY CLERK)

$____________   (Inspection fee paid)         DATE: _______________________, 20_______

$____________   (Connection fee paid)      SIGNED: _______________________________

                                          (CLERK)

   (APPLICATION APPROVED AND PERMIT ISSUED)

DATE: __________, 20_____   SIGNED: _____________________________________________

                  (PUBLIC WORKS DIRECTOR OR SUPERINTENDENT)

   APPLICATION FOR SANITARY SEWER SERVICE CONNECTION

   The undersigned, representing himself as owner of the property located at ___________________, hereby makes application for the sanitary sewerage service for said property, and in consideration of the furnishing of said service covenants and agrees as follows:

   1.   I agree to abide by all rules and regulations as specified in and by the ordinances of the village now in effect or ordinances enacted and passed from time to time providing for the regulation of the sanitary sewer system or specifying fees and rates to be charged for connection and sanitary sewer service furnished by the village. It is further acknowledged and agreed that the undersigned, his heirs, executors, administrators, successors and assigns shall pay all charges for connection fees and sewer usage which shall become due as the result of the connecting of the sewerage mains and the furnishing of sanitary sewer service to the above property, and that all such charges and fees for sanitary sewerage service rendered to the property, together with penalties, if any, and the costs of collection are to be considered and become a charge against the property, the lien so created to be enforced in accordance with the ordinances of the village.

   2.   All bills for the aforesaid charges are payable on or before the due date following the receipt of said bill and if not paid, are subject to a ten percent (10%) penalty.

   3.   Each and all of the agreements and covenants herein contained shall run with the real estate above described whose present owner is signatory to this application.

   4.   I understand that after making this application, I am to await installation permit and instructions therewith.

   5.   SERVICE CONNECTION FEE: $____________ is enclosed herewith, payable to the village.

   6.   Permission is hereby granted to the village and its authorized representatives at any reasonable time to enter the premises of the applicant and any portion thereof for the purposes of inspecting all connections appurtenant to the sewage outlets, pipes and mains.

____________________________    __________________________________

(APPLICANTS’ SIGNATURE)      (STREET NUMBER AND NAME OF STREET)

__________________________       _____________________________________

(OWNER’S SIGNATURE,         (VILLAGE, STATE AND ZIP CODE)
IF NOT APPLICANT)

                  _____________________________________

                  (TELEPHONE NUMBER)      (DATE)

Do not fill in the         MAIL BILLS TO:    (_____________________________________
spaces to the right                              (NAME)
if the information
is the same as the                   (_____________________________________
applicant above.                  (STREET NUMBER AND NAME OF STREET)

                        (_____________________________________

                        (VILLAGE, STATE AND ZIP CODE)

   RECEIPT

   Receipt is hereby acknowledged of the executed application for the sanitary sewer service connection from the person and for the property indicated below.

   This receipt does not authorize a service connection to be made. Inspection and approval of the customer service line by an authorized representative of the village and SCWRD is required, and approval of such connection and issuance of a certificate of inspection and approval and permit is conditioned upon compliance with all the ordinances, codes, rules and regulations of the village.

NOTE:

   1.   In the event the location of the sewer service connection is unknown, the Superintendent is to be contacted.

   2.   This office is to be notified the day before the work is to be done so that inspection may be arranged in accordance with specifications furnished. For example, if you desire inspection on Tuesday, contact us on Monday. If you desire inspection on Monday, contact us on Friday, etc.

   3.   Wastes from the basement as well as the other floor(s) of the property must go into the sanitary sewers. Downspout and surface drainage are prohibited inasmuch as this is not a storm sewer system.

WARNING!   In order to coordinate our inspections, we must be advised a day in advance before the work is done. The inspection must be made before the trench is backfilled. If trench is backfilled before the inspection is made, it will have to be reopened to permit inspection. Coordination with SCWRD inspectors is your responsibility.

NO. _________________________________________   VILLAGE OF ROCHESTER

                           COUNTY OF SANGAMON

DATE: _______________________________________

ADDRESS: ___________________________________

OWNER(S): __________________________________

_____________________________________________