Repair Permit Application

Lewisburg Area Joint Sewer Authority

Application for sewer repair permit

To: Lewisburg Area Joint Sewer Authority Lewisburg, Pennsylvania

MM slash DD slash YYYY
(I/We) hereby make application for permit to make necessary acceptable repairs to the sewer lateral connected to LEWISBURG AREA JOINT SEWER AUTHORITY sewer. The following facts are given as a basis for the permit:
(Borough of Lewisburg) (East Buffalo Township) (Buffalo Township)
The Property is bounded
on the North by
On the East by
On the South by
On the West by
 
(I/We) have read the Rules and Regulations of the LEWISBURG AREA JOINT SEWER AUTHORITY and agree to be bound by them, and warrant that (I am/ We are) the legal owner(s) or owner(s) authorized representative of the above described property.

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(I/We) have read the Rules and Regulations of the LEWISBURG AREA JOINT SEWER AUTHORITY and as contractor or sub-contractor on the building to which this permit refers, (I/We) agree to be bound by them.
If signer is an individual use this signature block. Print name exactly as it appears in the signature and enter the date of signature.
MM slash DD slash YYYY
(Seal)

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If signer is an individual trading under a fictitious name or represents a partnership, use this signature block. Print name exactly as it appears in the signature, give the business title of the signer, print the precise business name, and enter the date.
MM slash DD slash YYYY
(Seal)

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If signer is a Corporation, use this signature block. Fill in corporate name, sign, attest, date and affix the corporate seal.
MM slash DD slash YYYY
Secretary or Assistant Sec.

Lewisburg Sewer

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