TOWN OF BRADFORD – WATER & SEWER COMMISSION

RESIDENTIAL OR COMMERCIAL BUILDING

CHANGE OF SEWER DISCHARGE PERMIT APPLICATION

Please print this form – complete the following information and mail to:

Bradford Water & Sewer Commission

PO Box 603 – Bradford VT  05033

The undersigned, _________________________________, __________________________

                                    (Owner, Owner’s Agent)                          (Applicant)

of the property located at ____________________________________________ does

                                                (Number & Street)

hereby request a permit to change the volume and/or character of pollutants of discharge at the above said location.

1.         The maximum number of persons who will use the above building is ________.

2.         The maximum number of gallons requested per day is __________.

3.         Character of pollutants to be discharged are:  _________________________

            ______________________________________________________________

4.         The name and address of person or firm who will perform the proposed

work is:  __________________________________________________

            In consideration of the granting of this permit, the undersigned agrees:

1.         To accept and abide by all provisions of the Sewer Ordinance of the Town of Bradford as adopted on June 14, 1978, amended on May 24, 2007, and of all other pertinent ordinances or regulations that may be adopted in the future.

2.         To maintain the building sewer at no expense to the Town.

3.         To notify the Board of Water & Sewer Commissioners or their authorized agent when the building sewer is ready for inspection and connection to the public sewer and before any portion of the work is covered.

Date:  __________________  Signed _______________________________________

                                                                        (Owner, Owner’s Agent)

Date:  __________________  Signed _______________________________________

                                                                        (Applicant)

Address of Owner/Agent:  _________________________________________________

Address of Applicant:  _________________________________________________

$___________ fee received by:  _______________________

Application approved and permit issued:

Date:  __________________  Signed _______________________________________

                                                                        (Bradford Water & Sewer Commission)

Permit is valid for 2 years from date of approval.