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APPLICATION FOR RENEWAL OF CERTIFICATE OF WATER QUALITY
COMPLIANCE- Brewster Bylaw 179.53
Application Fee: $50.00
(Please Print)
PROPERTY OWNER’S NAME PHONE ( )
BUSINESS NAME+OWNER_________________________________________________________________PHONE________________________
MAILING ADDRESS
E-MAIL ADDRESS _________________________________________________________________________
PROPERTY LOCATION: MAP: LOT: STREET ADDRESS:
PREVIOUS APPROVED PERMIT DATE _______________________________
PLEASE COMPLETE THE FOLLOWING CHECKLIST
IF ANYTHING HAS CHANGED SINCE PREVIOUS PERMIT: A COMLETE APPLICATION MUST BE SUBMITTED
Answer YES or NO for each area. USE N/A if not applicable
1. Engineered site plan, filed previously, is the same as previous application:
______ a.) All property lines and ownership of abutting lots
______ b.) Current conditions and proposed finished grades and conditions, including all structures, fencing, signage,
paved areas, parking areas (with number of parking spaces delineate) and improvements, including re-vegetation and
landscaping plans. Include location of any existing and/or proposed groundwater wells and provide most recent well testing
data.
______ c.) All surface and subsurface treatments for the direction and retention of storm water and waste water, including
existing or proposed drains.
______ d) Provide the most recent monitoring or pumping data since last certificate;
Septic last pumped (date) _______________
Septic last inspected (date) ______________
2. No construction, clearing and excavation has occurred on the property since last certificate. __________
TOWN OF BREWSTER
WATER QUALITY REVIEW COMMITTEE
2198 Main Street
Brewster, Massachusetts 02631-1898
(508) 896-3701
FAX (508) 896-8089
3. The nature of commercial activity has remained the same since last certificate. ___________
4. Agricultural activity on the property:
______ a) Number of animals has remained the same since last certificate.
______ b) Fertilizer and Integrated Pest Management (IPM) plan has remained the same since last certificate.
______ c) Manure or animal waste management plan has remained the same since last certificate.
5. Equipment on site:
_____ a) All equipment stored on the property has remained the same since last certificate.
6. Traffic information, including protection against vandalism, provided in the original application has remained the same
______________
7. Equipment fueled on-site and precautions taken to prevent spills and actions proposed in the event a spill occur
has remained the same since last certificate.______________
8. List of all chemicals, pesticides, fuels, and other potentially toxic or hazardous materials has remained the same since
last certificate.______________
9. A description of potentially toxic or hazardous wastes to be generated on site or stored on site, indic ating storage
containment and disposal methods has remained the same since last certificate.______________
10. Description of measures that will be taken to protect materials and storage structures from corrosion and leakage
has remained the same since last certificate.______________
11. Description of measures that will be taken to control and contain spills of all potentially hazardous materials
Including fuels has remained the same since last certificate.______________
12. Description of any existing or proposed floor drains and dry wells has remained the same since the last
certificate.______________
13. List any non-sanitary wastewater generated at the property as a result of residential, commercial or agricultural
activities conducted at the property (services, maintenance, manufacturing, processing) has remained the same since the
last certificate.______________
Signature of Applicant
______________________________________________
Printed name of Applicant