Form Center

2. 
3. Date and Time of Approval
   Date and Time of Approval

   Date and Time of Approval
4. Inspection Fee

   1. $200 For Existing Property
   2. $2000 For New Construction
6. Owners Name/ Agents Name*
7. Email Address*
9. Address of Property Location*
11. City*
12. State*
13. Zip Code*
15. Owners/Agents Phone Number*
16. Dig Safe Number*
18. Name of Installer*
19. Installers Phone Number*
21. Please Read and Agree to the Following "Terms and Conditions" below
23. I agree and abide by all regulations of the water and sewer board, board of health and other appropriate board and officials as necessary*

    1. Yes
25. To Abide by the regulations of "Jackie's Law" as mandated by the Commonwealth of Massachusetts*

    1. Yes
27. To notify Dig Safe before starting excavation as per State and Town Laws*

    1. Yes
29. Where Fill Elevation are above 250 feet a Booster pump must be installed*

    1. Yes
31. To Notify Water Department when installation is ready for inspection*

    1. Yes
33. Owners Signature
35. Installers Signature
37. Water and Sewer Department Representative Signature
Leave This Blank:


38. Print Only

* indicates a required field