HomeMy Public PortalAboutWell ApplicationTOWN OF BREWSTER
2198 MAIN STREET
BREWSTER, MA 02631
PHONE: (508) 896-3701 EXT 1120
FAX: (508) 896-4538
BRHEALTH@BREWSTER-MA.GOV
WWW.TOWN.BREWSTER.MA.US
OFFICE OF
HEALTH DEPARTMENT
WELL PERMIT APPLICATION
No. Fee: $60.00
Application is hereby made for a permit to Construct ( ) Repair ( ) Demolish ( ) a well
Location-Address Map & Lot #
Owner Address
Driller Address
Type of building: DWELLING COMMERCIAL OTHER
Well use: CONSUMPTION IRRIGATION MONITOR OTHER
Design Capacity of Water System:
Nature of repairs/alterations:
Driller Registration #: Site plan included:
AGREEMENT: The undersigned agrees to install the aforedescribed well in accordance with the provisions of the Town of Brewste r
regulations for Private Wells. 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 for the following reasons:
PERMIT EXPIRES SIX (6) MONTHS FROM DATE OF ISSUE
CERTIFICATE OF APPROVAL
Lab report Completion report Certified Plot Plan Pump Test
This is to certify that the well constructed ( ) Repaired ( )
By: At:
Driller Location
Has been installed in accordance with the provisions of the Town of Brewster Regulations for Private Wells application for
Well Permit No: Dated:
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM
WILL FUNCTION SATISFACTORILY.
Date: Inspector:
BREWSTER BOARD OF HEALTH PERMIT
No.
Permission is hereby granted
to Construct ( ) Repair ( ) Demolish ( ) a well at:
As shown on the application for well permit No. Dated:
Date: Board of Health