NEWBURY BOARD OF HEALTH
APPLICATION FOR PERC TESTING A PARCEL OF LAND
Application and NON-REFUNDABLE fee must be returned to the Board of Health Office
For each lot (new) - $300 maximum 3 hrs 25 High Road
(repair) - $150 maximum 1 ½ hrs Newbury, MA 01951
$50 PER ½ HOUR OVERTIME CHG.
APPOINTMENT DATE: ________________________ TIME: ___________________
To be filled out by the Owner / Applicant
· NAME OF OWNER ________________________________________________
· NAME OF APPLICANT IF DIFFERENT FROM
OWNER __________________________________________________________
ADDRESS ____________________________________________________
TELEPHONE # TO CALL (7:30 A.M.-3:30 P.M.) ____________________
· PLOT PLAN TO BE SUBMITTED WITH APPLICATION ________________
· ASSESSESSORS’ MAP AND LOT NUMBER: MAP _________ LOT _______
· DESCRIPTION OF BUILDING
# OF BEDROOMS _____________________
USE _________________________________
INDICATE ( ) INSTALLATION FOR NEW BUILDING
( ) REPAIR OR REPLACEMENT OF EXISTING SYSTEM
· LOCATION (STREET & NUMBER) ___________________________________
NAME OF SUBDIVISION ________________________________________
SIZE OF LOT (SQUARE FEET) ___________________________________
· WATER SUPPLY: ( ) TOWN ( ) WELL
(ALL PRIVATE WELLS WILL BE CONSIDERED PART OF THE LOT SANITARY
REQUIREMENTS AND BE SUBJECT TO THE APPROVAL OF THE INSPECTOR
BEFORE FINAL BOARD OF HEALTH CERTIFICATE OF COMPLIANCE IS ISSUED.
ALSO PLEASE BE ADVISED OF STATE LAW SECTION 54 OF CHAPTER 40 OF THE
MGL “AVAILABITIY OF WATER SUPPLY” – REQUIRING THAT THE WATER
SUPPLY BE APPROVED BEFORE THE BUILDING PERMIT IS ISSUED.)
· NAME OF ENGINEER OR REGISTERED SANITARIAN _________________
· ADDRESS & TELE. # ______________________________________________
· SIGNATURE OF PROPERTY OWNER OR AUTHORIZED AGENT
· DATE ______________________
A SEPARATE APPLICATION AND FEE IS REQUIRED FOR EACH LOT TESTED
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