Form Center

2. Date:
   mm/dd/yyyy
4. Property Address for Fill Placement:*
6. Name of Property Owner*
7. Phone Number*
8. Email Address
10. Address of Owner (if different than fill location)
12. Business Name/Contractor Placing Fill*
14. Contact Name for Business*
15. Phone Number*
17. Source(s) of Fill*
19. Type of Fill*
21. Quality of Fill*
23. Length of Time of Fill Operation*
25. Fill Delivery Schedule*
27. Wetlands within 100 feet?*

    1. Yes
    2. No
28. Is the property in the 100-year floodplain?*

    1. Yes
    2. No
29. If no, is it subject to substantial flooding*

    1. Yes
    2. No
31. Will the placement of fill cause increased stormwater runoff or other flooding impacts on abutting properties?*

    1. Yes
    2. No
33. If no, how do you know?
35. A plan must be submitted along with this application showing the area of proposed fill.
37. I, the undersigned have read, understand and agree to abide by the Board of Health regulation regarding the placing of fill. I understand that I am responsible for demonstrating that the placement of fill does not cause increased stormwater runoff or other flooding impaces on abutting properties. I may be required to hire an engineer to certify that there are no adverse impacts.
39. I understand that it is my obligation to contact the Conservation Commission (781-721-7152), Engineering Department (781-721-7120) and the DPW Commissioner (781-721-7100). Applicant assumes full responsibility for the final grading of the fill and for it's impact, including but not limited to any adverse effects on adjacent property.
41. Signature of Property Owner*
    Please type in your full name. This will be considered an electronic signature.
42. Date
44. Applicant must obtain signatures from the following departments. Departments below are only signing as to their respective authority:
46. Conservation Commission:
47. Date
49. Conservation Commission Notes:
51. Engineering Dept:
52. Date
54. Engineering Dept. Notes:
56. DPW Director:
57. Date
59. DPW Notes:
61. Health Director:
62. Date
64. PAYMENT OPTIONS
    Payment must be made before application will be processed. Click the link below for online payment, or mail $50 check payable to "Town of Winchester," to Health Dept., 71 Mt. Vernon St, Winchester MA 01890.
66. Online Payment
    Application to Place Fill

    After payment is complete, you must return to this page and "submit" your application. Your application will be printed and returned to you to obtain the required signatures and be emailed to healthdept@winchester.us or mailed in to the Health Dept.
Leave This Blank:


68. 1. Receive an email copy of this form.
69. Email address

    This field is not part of the form submission.

70. Submit

* indicates a required field