Permit to Perform Work on Public Sewer System

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DEPARTMENT OF ENVIRONMENTAL MANAGEMENT WASTEWATER DIVISION COUNTYOFHAWAII–108RAILROADAVENUE–HILO,HI96720-4252 HILO (808) 961-8338 FAX (808) 961-8644 PERMIT TO PERFORM WORK ON THE PUBLIC SEWER SYSTEM Pursuant to the provisions of Chapter 21 of the Hawai’i County Code, application is hereby made for a permit to connect to an existing sewer lateral, install a new sewer lateral, demolish an existing structure connected to the system, and/or install a sewer main extension to the public sewer system. TMK # (3) - - : Project Name: APPLICANT INFORMATION: Name: Mailing Address: City, State Zip: Telephone: Cellular: Email Address: Contact Name and Telephone Number (if different from above): TYPE OF CONNECTION: Existing Sewer Lateral connection. Attach a plot plan indicating the location of the sewer lateral and COTG in relation to the property line. Single Family Residential Construction Multi-Unit/Non-Residential Construction Enter Number of Residential/Non-Residential Units Installation of a new sewer lateral. Attach an approved plot plan indicating the location of the sewer lateral and COTG in relation to the property line. Single Family Residential Construction. Multi-Unit/Non-Residential Construction Enter Number of Residential/Non-Residential Units Demolition of a residential/commericial property. Follow COH Wastewater Standard Detail WW-8 for disconnection. Submit an existing plot plan noting the location of the existing sewer cleanout. Number of Units to be demolished The Permittee shall provide 48 hours notice prior to commencement of work by calling (808) 961-8512 (Hilo Area) or (808) 327-3515 (Kona Area) for inspection. Sewer Lateral Connection, installation (Approximate Date of Work) and/or demolition will be made on: Sewer Lateral Connection and/or New Sewer Lateral Installation : Connection to an existing sewer lateral and/or installation of a sewer lateral shall comply with Section 21-22 of Chapter 21 of the Hawai’i County Code, as well as the current Wastewater Sewer Notes and Standards issued by the Wastewater Division. Copy of the standard Wastewater Sewer Notes and Details are available at our office at 108 Railroad Avenue. In consideration of granting this permit, the Permittee understands AGENCY USE ONLY and agrees to abide by all rules and regulations which are applicable and required by law. Final Acceptance Date: Inspector Signature: Permittee’s Signature Date Plumber of Record: Plumbing Permit No: APPROVED BY WWD: Permit No: Date Signature of Authorized Representative Date Hawai`i County is an equal opportunity provider and employer.