TO THE CLERK: | |
The undersigned, being the (owner[s]) of the property located at (address) does hereby request a permit to install sanitary sewage disposal facilities to serve the (residence/commercial building and the like). | |
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 200 feet (61 meters) of any boundary of the property are shown on the plat attached hereunto as Exhibit “B”. | |
6. Installation contractor’s registration with the village (Exhibit C). | |
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 village. | |
2. To accept and abide by all provisions of the Village Code and of all other pertinent codes or ordinances 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 this village and at no expense to the village. | |
4. To notify this municipality at least 48 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) | |
$ (Inspection Fee Paid) | DATE: |
$ (Connection Fee Paid) | SIGNED: |
(CLERK) | |
(APPLICATION APPROVED AND PERMIT ISSUED) | |
DATE: , | SIGNED: |
Village of Shiloh | |
To view this application in PDF, click here.