Town of Fayston
APPLICATION FOR DISPOSAL SYSTEM USE PERMIT
CERTIFICATE of WASTEWATER COMPLIANCE
Owner(s) of Property:
Mailing Address:
Telephone:
Applicant(s) (if different than owner(s)):
Mailing Address:
Telephone:
Physical Location of Property:
Parcel ID Number:
Tax Map Number:
Property is Located in Zoning District:
[ ] Rural Residential District
Acreage:
[ ] Soil & Water Conservation
[ ] Irasville Commercial District
Flood Zone:
[ ] Recreation District
[ ] Resort Development District [ ] Flood overlay
I do hereby certify that the sewage disposal system or modification approved under Disposal System
Construction Permit Number ______ issued by the State of Vermont on _______________ was inspected by
me prior to be covered with soil, and
[ ] the system or modification was installed in accordance with the plans submitted with the application for the
Construction Permit, or
[ ] the system or modification as installed varies from the plans as described below but that the variations comply
with Vermont Department of Environmental Conservation Small Scale Wastewater Treatment and Disposal
Rules, Subchapter 7, effective January 1st, 2005, or
[ ] To the best of my knowledge the existing sewage disposal system was exempt from the above described
Rules, that it was not reasonably possible to install a system which complied strictly with the Rules, and that
the system as installed varies from the plans submitted with the application for Construction Permit as
described below but that the system is reasonably designed to abate or prevent a health hazard, the surfacing of
sewage, the contamination of drinking water, groundwater, and surface water, and will not adversely impact
sanitary and healthful conditions for the occupants of the property served thereby or otherwise.
Date: ___________________
________________________________________________
Vermont Licensed Professional Engineer or Type B Certified Site Technician
-----------------------------------------------------Office use only
Permit number ___________
___ Approved
Date ___________
Date permit is valid ____________
Date received ____________
___ Denied
Date ___________
Fee paid ________________
___ Referred to: _____
Date ___________
Zoning district ___________
Related applications:
_____________________________________
Action: _____________
Wastewater Officer’s Signature: _______________________________________
___________________________________________________________________________________________
Town of Fayston, Vermont
Certificate of Occupancy  Certificate of Wastewater Compliance
Permit Form Instructions
Fayston Town Office  866 North Fayston Road  North Fayston, VT 05660
Zoning and Planning Administrator: 802-496-2454 ext. 25  Town Clerk: 802-496-2454 ext. 21
Certificates of Wastewater Compliance are required after a wastewater system has been installed, constructed,
altered, replaced, or repaired. All wastewater systems that required a State of Vermont Wastewater Permit also
require a Certificate of Wastewater Compliance by the Town of Fayston. Certificates of Wastewater Compliance
verify that the wastewater system was installed according to the design submitted with the Wastewater Permit
application. The Certificate of Wastewater Compliance Permit application should be submitted when the
construction on the wastewater system is complete. For more information, contact the Zoning Administrator at
496-2454 ext. 25.
Fayston also requires permits for the construction of buildings, septic systems, driveways off town roads, and the
subdivision of land. State and federal permits also are required for some types of land development; for more
information, contact the state permit specialist at 802-476-0195. Copies of all Fayston permit application forms,
and the Fayston Wastewater Ordinance, Fayston Land Use Regulations, and Fayston Town Plan are available by
mail or at the Town Office during regular business hours from 9:00 to 3:30, Monday through Friday.
To fill out this form, please answer the questions on the reverse side of this application. In addition, a Vermontlicensed engineer or Certified Site Technician must inspect each wastewater system that requires a Certificate of
Wastewater Compliance before it is buried and certify to the Town that the system was installed substantially in
accordance with the previously approved design. Any variations from the approved design should be noted in the
report.
Return this application, the materials listed above, and the permit fee of $20 to the Town Office at the address
listed above. If the Town of Fayston Wastewater Officer finds that your application is complete, you will be
issued your permit by mail.