TO THE VILLAGE OF _______________________________:
   The undersigned, being the ________________________________ of the property located at
               (owner, lessee, tenant, etc.)
______________________________________, does hereby request a permit to install an industrial
(residence, commercial building, etc.)
sewer connection serving the ___________________________________________________________,
               (Name of company)
which company is engaged in ______________________________ at said location.
1.   A plan of the property showing accurately all sewers 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 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 any waste pre-treatment facilities, as may be required as a condition of the acceptance into the public sewer industrial wastes involved, in an efficient manner at all times, and expense to the Village.
4.   To cooperate at all times with the Superintendent and his representatives in their inspecting, sampling, and study of the industrial wastes, and any facilities provided for pre-treatment.
5.   To notify the Superintendent 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.
DATE: ____________________   SIGNED:    ____________________________________
$ _________________________ (inspection fee paid)   ____________________________________
                        (Address of applicant)
Application approved and permit issued:
DATE: ___________________________   ___________________________________