2. Permit #
3. To the Director of Health - Town of:
4. Date
6. Application is hereby made for a permit to construct a sewage disposal system for a:*

   1. Residential Building
   2. Restaurant

   1. Retail Building
   2. Other
7. Application Fee Paid $
9. Located at: Street Address
11. Map #
12. Block #
13. Lot #
14. Subdivison Name
16. Type of Request*

    1. New System

    1. Addition

    1. Repair

    1. Other
18. Owner's Name ( as it appears on land records)
19. Phone Number
21. Address
23. City
24. State
25. Zip Code
27. Installer's Name
28. License #
30. Address
32. City
33. State
34. Zip Code
36. Phone Number
37. Fax Number
39. Electronic Signature Agreement

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
41. Electronic Signature*
    (Owner or duly authorized representative)
43. General Information
44. Soil Tests Conducted (Date)
45. Lot Size (sq. ft)
47. Area of Special Concern (Yes/No)
48. If yes, Reason(s)
50. Basis of Design (# of Bedrooms, Restaurant Seats, Building Size, etc)
52. Engineered Plan Required (Y/N)
53. If yes, Name of Engineer
55. Address of Engineer
57. Design Plan Approved (Y/N)
58. Date of Approved Plan
59. Revision Date
61. Type of Water Supply
62. If well, has location been approved (Y/N)
64. Well Driller’s Name
66. Address
68. Office Use Only
70. Approval to Construct is hereby issued by
    Print Name
71. Date
73. Signature
74. Title
76. Note: Approvals to construct can only be issued by the Local Director of Health or Registered Sanitarian
Leave This Blank:


78. 1. Receive an email copy of this form.
79. Email address

    This field is not part of the form submission.

80. Submit

* indicates a required field