INCORPORATED VILLAGE OF BAYVILLE

APPLICATION FOR SANITARY DISPOSAL SYSTEM PERMIT

(Pursuant of Chapter 61 of the Code of the Village of Bayville)

PERMIT NO.
FEE: $50
SECTION BLK.
LOT ZONE
Application to be filled out in duplicate. Indicate on plot plan below location of system with respect to building it serves. Two copies of property survey must accompany this application.
Owner NAME
ADDRESS
TELEPHONE NO.
Contractor NAME
ADDRESS
TELEPHONE NO.
Insurance WORKMAN'S COMPENSATION POLICY NO.
AGENT
DATE OF EXPIRATION
DESCRIPTION OF SANITARY DISPOSAL SYSTEM
___________________ Signature of Applicant