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PERMIT APPLICATION FORMS
PRIVATE WASTE DISPOSAL APPLICATION
TO THE VILLAGE OF ____________________________:
The undersigned, being the ___________________________ of the property located at
(owner; owner's agent)
______________________________________, 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 the Revised Code of the Village, and of all other pertinent codes 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 Superintendent and at no expense to the Village.
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: ___________________________
$ ____________ (inspection fee paid) _______________________________________
(Address of Applicant)
Application approved and permit issued: