Sewer Connection

Public Sewer System Connection Application Town of Lousia, Virginia
TO BE COMPLETED BY APPLICANT
Please attach sketch of building, sewer line from building to desired location on property boundary line on 8½x11 paper. (Give approximate measurements.)
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sketch of building, sewer line from building to desired location on property boundary line
Property Owner Signature
This sewer connection permit is null and void if conditions are changed from those shown on the application or sketch. If connection to the public sewer system is not completed within 6 months from date of issuance, this permit must be revalidated and any additional connection fee paid as established by the connection fee schedule in effect on the date of revalidation.
Upon connection to the public sewer system, the property owner agrees to pay for all sewage discharged into the town system.
Issued by:

Date of Inspection: ____/____/____
Action Taken: □ Approved □ Rejected
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Inspector
Sending