Repair Permit Application

Lewisburg Area Joint Sewer Authority

Application for sewer repair permit

To: Lewisburg Area Joint Sewer Authority Lewisburg, Pennsylvania

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(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.
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(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.
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(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.
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Secretary or Assistant Sec.