(A) Private sewage disposal application.
PRIVATE SEWAGE DISPOSAL APPLICATION (NON-INDUSTRIAL) |
To the City of _________________________________: |
The undersigned, being the _____________________________________________ |
(owner, owner’s agent) |
of the property located at _______________ , _____________________ |
(number) (Street) |
does hereby request a permit to install sanitary sewage disposal facilities to serve the |
___________________________________ at said location. |
(Residence, Commercial Bldg.) |
1. The proposed facility include the following material which is to be used: ____________________ |
___________________________________________ with ________ types of joints (applicant contact plumber or Superintendent for joint types.) |
2. The area of the property is ____ square feet. |
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 facility is ____________________. |
5. The location and nature of all sources of private water supply within 100 feet of any boundary of said property are shown on the plat attached hereto as Exhibit B. |
In consideration of 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 of Sewage Works, or other officer or employee appointed for such purpose. |
2. To accept and abide by all provisions of Ordinance No. _________of the City of Whitewood, and of all other pertinent ordinances or regulations that maybe adopted in the future. |
3. To operate and maintain the sewage disposal facility covered by this application in a sanitary manner at all times, in compliance with all requirements to the Health Officer, and at no expense to the City. |
4. To notify the Superintendent of Sewage Works, or other officer or employee appointed for such purpose, at least 24 hours prior to commencement of work proposed, and again at least 24 hours prior to the covering. |
Dated ___________________ Signed ________________________________ |
(Applicant) |
_________________________________________________ |
(address of applicant) |
$______ inspection fee paid. ___________________________________ |
City Finance Officer |
Application approved and permit issued: |
Date: ___________ Signed ________________________________ |
Superintendent |
(B) Industrial sewage disposal application.
INDUSTRIAL SEWAGE DISPOSAL APPLICATION |
To the City of ______________________: |
The undersigned being the _______________________________ |
(Owner, Lessee, Tenant, etc.) |
of the property located at ___________________________________ does hereby request a permit to (install, use) an |
industrial sewer connection serving the ________________________________ |
(name of company) |
which company is engaged in ___________________________________________________ |
______________________________________ at said location. |
1. A plat 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 the permit is sought as may be requested by the Superintendent of Sewage Works, or another officer or employee of the City of Whitewood appointed for such purpose. |
2. To accept and abide by all provisions of Ordinance No. ___________ of the City of Whitewood, and of all other pertinent ordinances or regulations that may be adopted in the future. |
3. To operate and maintain 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 city. |
4. To cooperate at all times with the Superintendent of Sewage Works and his representatives in their inspecting, sampling, and study of the industrial wastes, and any facilities provided for pretreatment. |
5. To notify the Superintendent of Sewage Works 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: ______________________________ |
Applicant |
_____________________________________________ |
Address of Applicant |
$_______ inspection fee paid. ____________________________________ |
City Finance Officer |
Application approved and permit granted: |
Date: ______________ Signed: _______________________________ |
Superintendent |
(Prior Code, Appendix A)