Village of Bergen,
New York
11 Buffalo Street
P.O. Box 100
Bergen, NY 14416
Ph: (585)494-1513 ---- Fax: (585)494-1730
picture of train
Proudly located in Northeastern
Genesee County

APPLICATION FOR COMMERCIAL AND INDUSTRIAL SEWER CONNECTION
to
Village of Bergen Sewer System

Applicant must provide drawings or engineering plans & special for building to be reviewed by the Village Code Enforcement Official or the Superintendent of Sewers.


Name & Address of Owner:____________________________________________________

__________________________________________________________________________

Phone__________________

 

Name & Address of Architect orEngineer:__________________________________________

__________________________________________________________________________

Phone: ________________________ Fax: _________________________

Email: _____________________________________________________________________

 

Tax map number of property where sewer is being constructed __________________________

Square ft. of building_____________

Number of toilet rooms: Employee______ Public______

Kitchen facilities [ ] Yes [ ] No
If yes, is there a garbage disposal being installed? [ ] Yes [ ] No
Will there be a grease trap? [ ] YES [ ] NO

Projected water usage per day___________

Number of separate businesses operating in the premises ________________________________

Signature of applicant___________________________________________________________

Date______________

-----------------------------------------------------------------------------------

TO BE COMPLETED BY VILLAGE

Size of septic tank required__________________________________________

Number of units for Inspection, connection and capital facility fees ___________

TO CLERK'S OFFICE: Number of units for capital facility, connection, and inspection fee______________
FEES: Inspection fee ________ units x $50 = $_________ Received________
Connection fee_______ units x $150 = $_________ Received_____________
Capital facility fee _______ units x $1,250 = $_________ Received_________

TO UTILITY BILLING OFFICE
Number of units for debt sewer charge billing purposes __________________________ (refer to section 2 OF Local Law #6 of 1985)

Action ---------------------------------------------Signature of official and date Easement received and approved __________________________________ Plans reviewed and approved _____________________________________ Inspection completed ___________________________________________ Date of hook-up _______________________________________________ Sets of as built drawings received ______ /____________________________ Certificate of occupancy issued ______ /_____________________________

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