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DISPOSAL WORKS INSTALLER’S PERMIT RENEWAL
Application for permit to engage in the construction, alteration, installation or repair of any individual sewage
system. If all information is correct and the blanks filled in, please sign and return to the Health Department along
with the FEE and the State required WORKERS COMPENSATION INSURANCE AFFIDAVIT FORM. No permit
will be issued if form is not returned. Should corrections be needed, please make them.
Fee: $110.00
1. Full name of applicant:
2. Business Name:
3. Mailing address:
(if different from above)
4. Business address location:
5. Telephone #:
6. Type of business:
7. State your experience in this field:
8. Towns where current licenses are held:
9. Are you familiar with the Massachusetts Sanitary Code Regulations, Title 5: Minimum Requirements for the
Subsurface Disposal of Sanitary sewage?
10. I understand that no system will be installed until the Health Agent inspects the over dig:
11. I understand that no system will be covered until inspected:
12 I understand that any violation of the Health Laws in regard to the installation of a sewage system will result in
REVOCATION of my permit, which may mean prosecution or both. This permit will expire December 31,
13. I HEREBY STATE THAT ALL ANSWERS ARE CORRECT AND UNDERSTOOD OR HAVE BEEN
CORRECTED.
Applicant Signature:
Title: Date:
*Enclose application, fee and workers compensation insurance affidavit*
Town of Brewster
Health Department
2198 Main Street
Brewster, Massachusetts 02631-1898
(508) 896-3701 X1120
FAX (508) 896-4538