HomeMy Public PortalAboutApplication for Disposal System Construction Permit No. Date :
Repair : $30 . 00 (Minor i . e . : broken pipe, d-box, move tank)
$60 . 00 (Major i. e . : replace SAS, first 500 gallons)
$60 . 00 (Each 500 gallons after)
New : $ 110 . 00 (First 500 gallons)
$60 . 00 (Each 500 gallons after)
BREWSTER, MASSACHUSETTS
BOARD OF HEALTH
Application for Disposal System Construction Permit
Application is hereby made for a permit to construct ( ) or repair ( ) an individual sewage Disposal system at:
Location-Address Map and Lot No.
Owner Address
Installer Address
Designer Address '
Type of Building Lot Size sf
Dwelling-No , of bedrooms Expansion Attie o Garbage Grinder o
Other — Type of Building No . of persons Showers o Cafeteria o
Other fixtures
Design Flow gallons per day Calculated flow gallons
Plan : Date No . of sheets Revision Date :
Title
Type of system Trench o Field o Galley o Tank ❑
Description of Soil
Town Water o Private Well o (If well is checked , water testing results must be submitted with this application)
Zone II: Yes o No n
Nature of repairs or alteration (answer where applicable)
Date last inspected PERMIT EXPIRES ONE YEAR FROM DATE OF ISSUE
Agreement: The undersigned agrees to install the aforedescribed on-site Sewage System in accordance with the provision of Title 5
and the State Environmental Code . The undersigned further agrees not to place the system in operation until a Certificate of
Compliance has been issued by the Board of Health.
Signed :
Date
Application approved by
Date
Application Disapproved/Restrictions
No . Fee
BREWSTER, MASSACHUSETTS
BOARD OF HEALTH
Disposal Works Construction Permit
Permission is hereby granted to
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to construct o or Repair o an on-site Sewage Disposal System
at Lot Map
and as described in the above application for Disposal System Construction Permit. The applicant recognizes his/her duty to comply
with Title 5 and the following local provisions or special conditions
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Date Approved by i
Health Director
PERMIT EXPIRED ONE YEAR FROM DATE OF ISSUE '
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