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RESIDENTIAL OR COMMERCIAL BUILDING SEWER 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 said location.
(residence, commercial building, etc.)
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 fixture(s) 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 sewer are attached hereunder as Exhibit "A".
In consideration of the granting of this permit, the undersigned agrees:
1. 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.
2. To maintain the building sewer at no expense to the Village.
3. To notify the Superintendent when the building sewer is ready for inspection and connection to the public sewer, but before any portion of the work is covered.
DATE: ______________________ SIGNED: __________________________________
$ ____________ (inspection fee paid) ___________________________________________
(Address of Applicant)
Application approved an permit issued:
DATE: __________________________________ (Certification)