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Utilities Forms

APPENDIX #3

 

VILLAGE OF WESTVILLE

 

PRIVATE WASTE DISPOSAL APPLICATION

(SEPTIC TANK ETC.)

 

            The undersigned, being the ___________________________________________________ of the property

                                                            (owner, owner’s agent)

located at ____________________________________________________ does hereby request a permit  to  install

                        (Number)                       (Street)

sanitary sewage disposal facilities to serve the ___________________________________________ at the location.

                                                (residence, commercial building, etc.)

 

1.         The proposed facilities include: ____________________________________________________ to be constructed in complete accordance with the plans and specifications attached hereunto as Exhibit “A”.

2.         The area of the property is [_______] square feet or [_______] square meters.

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 facilities is                                             

5.         The location and nature of all sources of private or public water supply within one hundred (100) feet [30.5 meters] of any boundary of said property are shown on the plat attached hereunto as Exhibit “B”.

 

 

IN CONSIDERATION OF THE GRANTING OF THIS PERMIT, THE UNDERSIGNED AGREES:

 

 

1.         To furnish any additional information relating to the proposed work that shall be requested by the Village.

2.         To accept and abide by all provisions of the Revised Code and of all other pertinent codes or ordinances that may be adopted in the future.

3.         To operate and maintain the wastewater disposal facilities covered by this application in a sanitary manner at all times, in compliance with all requirements of the Village and at no expense to the Village.

4.         To notify the Village at least twenty-four (24) hours to commencement of the work proposed, and again at least twenty-four (24) hours prior to the covering of any underground portions of the installation.

 

DATE: ___________________________________, 20______    SIGNED:                                                            

                                                                                                                        (APPLICANT)

 

                                                                                                                                                           

                                                                                                            (ADDRESS OF APPLICANT)

 

(CERTIFICATION BY CLERK)

 

$__________   (Inspection Fee Paid)                                DATE:    ___________________________, 20_____

 

$__________      (Connection Fee Paid)                               SIGNED:___________________________________

                                                                                                                        (CLERK)

 

(APPLICATION APPROVED AND PERMIT ISSUED)

 

DATE:    ________________________________, 20______      SIGNED: ___________________________________

                                                                                                         (PUBLIC WORKS DIRECTOR OR SUPERINTENDENT)

 

 

APPENDIX #1

 

VILLAGE OF WESTVILLE

 

APPLICATION FOR WATER SYSTEM SERVICE CONNECTION

 

 

            The undersigned, representing himself as owner of the property located at                                                                                                                                   , hereby makes application for connection to the Water System of the Village for said property, and in consideration of the furnishing of said service covenants and agrees as follows:

 

1.         I agree to abide by all rules and regulations as specified in and by the ordinances of the Village now in effect or enacted and passed from time to time providing for the regulation of service furnished by the Village, it is further acknowledged and agreed that the undersigned, his heirs, executors, administrators, successors and assigns shall pay all charges for connection fees and water usage which shall become due as the result of the connecting of the water mains and the furnishing of water service to the above property, and that all such charges  and  fees for water service rendered to the property, together with penalties, if any, and the costs of collection are to be considered  and  become a charge against the property, the lien so created to be enforced in accordance with the ordinances of the Village.

2.         All bills for the aforesaid charges are payable on or before the due date following the receipt of said bill and if not paid, are subject to a ten percent (10%) penalty.

3.         Each and all of the agreements and covenants herein contained shall run with the real estate above described whose present owner is signatory to this application.

4.         I understand that after making this application, I am to await installation permit and instructions therewith.

5.         SERVICE CONNECTION FEE:  $ ___________ is enclosed herewith, payable to the Village.

6.         Permission is hereby granted to the Village and its authorized representatives at any reasonable time to enter the premises of the applicant and any portion thereof for the purposes of inspecting all connections appurtenant to the Water System.

 

 

CONNECTION MUST BE INSPECTED BEFORE BACKFILLING:

 

 

SIGNATURE:                                                                                                                                          

 

                                                                                                                                                           

                                                                                    (STREET NUMBER AND NAME OF STREET)

 

                                                                                                                                                           

                                                                                    (VILLAGE, STATE AND ZIP CODE)

 

                                                                                                                                                           

                                                                                    (TELEPHONE NUMBER)                             (DATE)

 

                                                                                    (

Do not fill in the                            MAIL BILLS TO:               (__________________________________________

spaces to the right                                                                        (NAME)

if the information                                                              (__________________________________________

is the same as the                                                            (STREET NUMBER AND NAME OF STREET)

applicant above.                                                               (

                                                                                    (__________________________________________

                                                                                    (VILLAGE, STATE AND ZIP CODE)

 

 

APPENDIX #2

 

VILLAGE OF WESTVILLE

 

UTILITY MAIN EXTENSION CONTRACT

 

            AGREEMENT made and entered into this _______ day of _______________________, by and between the Utility System of the Village of Westville, Illinois, hereinafter called the “Utility Department” and _________________________________________, hereinafter called the “Depositor”.

 

FIRST:            That the Utility Department contracts and agrees to have installed by contract in accordance with its rules, utility mains as shown on the plat thereof, and the specifications are attached hereto and made a part hereof.

 

SECOND:      Bids having been taken and the lowest responsible bid having been in the amount of $____________________, the Depositor agrees to deposit and does deposit herewith the cost thereof.

 

                              (A)      The lowest responsible bid $__________________.

                              (B)      Engineering and Inspection Charge $___________.

                              (C)      TOTAL: $________________________________.

 

THIRD:         Final costs to be adjusted up or down according to completed job cost.

 

FOURTH:      The ownership of the utility mains laid herein shall be at all times in the Utility Department, its successors and assigns.

 

FIFTH:          This Agreement shall be valid and binding on the Utility Department only when signed by the Mayor and Clerk.

 

SIXTH:         This Agreement shall be binding upon the heirs, executors, administrators, successors or assigns of the respective parties.

 

          EXECUTED in duplicate by the parties hereto on the date first above written.

 

                                                                      UTILITY DEPARTMENT

                                                                                    VILLAGE OF WESTVILLE

 

                                                                                    BY:                                                                   ATTEST:                                                                            PUBLIC WORKS DIRECTOR

                                                                                                                                                           

VILLAGE CLERK                                                        DEPOSITOR

 

WITNESSES:

 

____________________________________

____________________________________

 

APPENDIX #6

 

VILLAGE OF WESTVILLE

 

UTILITY SHUTOFF HEARING NOTICE

 

          This notice is being sent to you pursuant to the provisions of CHAPTER 38 OF THE REVISED CODE OF ORDINANCES as adopted by the corporate authorities.

 

CUSTOMER’S NAME:                                                                                                      

 

ADDRESS:                                                                                                                   

 

TOTAL AMOUNT OF BILL:     $_____________WATER

                             

                                        $_____________GAS

 

                                        $_____________OTHER

                                                                                SUB-TOTAL:   $_____________

 

                                                                                PENALTY:       $_____________

         

                                                                                TOTAL DUE:   $_____________

 

DATE OF HEARING ________________________________

 

TIME OF HEARING_________________________________

 

LOCATION OF HEARING                                                                                                

 

                                                                                                                                 

 

PHONE:                                                                                                                       

 

          If the consumer/customer fails to appear at the hearing, the applicable utility services shall be terminated [shut off] without further proceedings.

          If payment for the charges and fees is received prior to the date of the hearing, you may disregard this hearing notice.

          The Mayor and Village Clerk, or their designated representative(s), shall preside at the hearing.

                                                                                                                                 

                                                                      VILLAGE CLERK

 

            DATED THIS __________ DAY OF  __________________________, 20______.

 

NOTE:             After services have been shut off there will be a reconnection fee of $______________.

 

APPENDIX #7

 

VILLAGE OF WESTVILLE

 

OBJECTIONABLE MATERIAL EFFLUENT LIMITS

 

 

Waste or Chemical                                                              Concentration mg/l

 

Boron                                                                                 1.0

 

Chromium (Hexavalent)                                                         5.0

 

Chromium (Trivalent)                                                           10.0

 

Copper                                                                               3.0

 

Cyanide                                                                              0.005

 

Iron                                                                                 15.0

 

Lead                                                                                  0.1

 

Mercury or its compounds                                                      0.005

 

Nickel                                                                                 3.0

 

Oil & Grease, etc. (carbon tetrachloride extraction)                   100.0

 

Temperature not over 150º F. (65º C.)                                      

 

Acid iron pickling waste or concentrated plating waste              Zero

 

Free acids and alkalis pH                                            Between 5.5 and 9.5

 

Zinc                                                                                   2.0

 

Cadmium                                                                            2.0

 

Chlorine Demand                                                                30.0

 

Phenols                                                                              0.5