2. 

3. 
   

   
   

   City of Ellisville

   1 Weis Avenue

   Ellisville, Missouri 63011

   Phone: 636.227.9660   *   Fax: 636.227.9486

   
   

   SEWER PERMIT APPLICATION
   

5. Date:*
   Date:
7. Project Address:*

9. $0.70 Fee/Linear Foot of Storm Sewer

11. Storm Sewer (per Linear Foot) QTY*
13. Lot #:*
15. Subdivision:

17. Contractor Information:

19. Company Name:*
21. Main Phone #:*
22. Fax Phone #:
23. Contact Cell Phone #:*
25. Address:*
27. City:*
28. State:*
29. Zip:*
31. Contact Email:
33. Ellisville License #:
34. St. Louis Co. License #:*
35. St. Louis Co. Bond Exp. Date:*
    St. Louis Co. Bond Exp. Date:

37. Property Owner Information:

39. Owner Name:*
41. Owner Address:*
43. City:*
44. State:*
45. Zip:*
47. Owner Email:
49. Owner Phone / Cell #:*
51. Signature of Applicant:*
52. Date: *
    Date:

54. This permit expires 90 days after issuance. All material and workmanship will be in strict compliance with City Ordinances relative to such work and shall be approved by the sewer inspector before and after back filling.

    ============================================================================== ~ Office Use Only ~
    

    
    

    
    

56. PERMIT #:
58. CODE SECTION 22-26, A & B
60. PERMIT QTY:

61. PERMIT FEE: $5

62. Permit Fee Amount Due: $
64. INSPECTION QTY:

65. INSPECTION FEE: $55

66. Inspection Fee Amount Due: $
68. STORM SEWER : (PER LFT)

69. STORM SEWER FEE: $0.70 per LFT

70. Storm Sewer Fee Amount Due: $
72. EXTRA CHARGES: $
73. Description of Other Charges:
75. TOTAL AMOUNT DUE: $
77. APPROVED BY:
79. DATE:
    DATE:

81. Version: 01/17/2020

Leave This Blank:


83. 1. Receive an email copy of this form.
84. Email address

    This field is not part of the form submission.

85. Submit

* indicates a required field