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Department of Environmental Management Wastewater Division, County of Hawai'i Application For Sewer Extension Part A . (must be completed) Project Address: 34 Rainbow Drive, H i l o Date: 3/14/11 TMK No.: (3) 2-3-26:008 Applicant Information: Contractor Information: Name: Warren H. W. Lee Name: Address: 101 Pauahi Street, Suite 7 Address: Company: Department of Public Works Company: Phone No.: 961 -8321 Phone No.: Check applicable box: [9 Sewer Main Installation (Indicate reason for work and complete Parts B & C.) ❑ Sewer Lateral Installation (Indicate reason for work and complete Part C) Reason For Work: Large Capacity Cesspool Closure Part B. Sewer extensions are subject to Hawai'i County Code, Chapter 21, Division 4, Extensions and the APPLICANT shall be responsible for submitting a resolution to the County Council for approval of the sewer main extension Select one of the following methods of payment for cost and construction: (Note: reimbursement refers to payments collected by the County from properties connecting to the extension) Section 21- 28(a): Applicant constructs and pays. Section 21- 28(b)(1): County constructs, applicant pays. ❑ Section 21- 28(b)(2): County constructs, applicant and County share cost. ❑ Estimated Start Date 4/15/11 Estimated Completion Date 7/ 15/ 1 1 Part C. I hereby certify that a, work requested above will conform to appropriate sections of the Hawaii County Code. Owner Signature. U�IJ(f� t/lrl/ Date: W ,en H. W. Lee, Director Department of Public Works Department of Environmental Management, Wastewater Division Approved by: - ~'� Date: 711A Wastewater Division Chief � 7 Approved by: ID� Date: 3 I r r l1I 1 Director of Environmental Management Note: 1) Approval of the Application for Sewer Extension does NOT constitute approval for construction. Approval for construction is provided by an approved Permit to Perform Work on the Public Sewer System pending final approval by the Hawai'i County Council in accordance with Section 21 -26.1 of the Hawai'i County Code. 2) Filing of Sewer Extension Resolution is not required for sewer lateral installations. Hawaii County is an Equal Opportunity Provider and Employer 0:AWastewater \FORMS \070202 Sewer Extension Application- Final.doc EXHIBIT "A" (1)