341 Septic Application & Permit 4/29/14 BOARD OF HEALTH
City of Northampton
APPLICATION FOR A WELL CONSTRUCTION PERMIT
Well Permit Number/0/Ni (TO BE ASSIGNED BY BOARD OF HEALTH)
Fee $5,0.00
�J 1�1
This application must be accompanied by a scaled plot plan, produced by a civil engineer or registered
sanitarian showing the minimum distances required in Title 5 of the State Environmental Code. For new
construction, requiring a septic system, the septic system plan submitted for the property in compliance
with Title 5 requirements will be acceptable if the proposed well location is included.
Application is hereby made to construct( repair( )a private well.
tn Pie&TT /1/i; wso
-vt
Owner's Name
3Y 1 Fly ( brit reel
Street Address
N 3u,F
City, State, Zip Code
5'- .2y -iv
Date
y/3 - - L 9.4
Telephone Number
rile"O<,/4' 4J:LCv )
Location of Proposed Well
(if different from address)
/A2/lP LLB_ /46--tiss/tu
Tax Map N
Well Driller(submit evidence of valid state registration)
For new construction:
Septic system plan complies with Title 5:
Septic system plan shows location of well:
Con rvatiommissr Approval
na
(SLat alley ,northamptonma.sov)
yes () no () n/a O 445, e carded
Parcel N
yes (ono ( ) n/a( )
For new, repair or location to leach field, septic tank or city sewer:
A scaled well construction plan has been submitted:yes ( ) no ( ) n/a( )
frieZ i? F/P/u5 rf t.L)
Signature of Applicant
/jpe,e& .t_ las,.:unJ l.ra
Please Mail Application to:
Northampton Board of Health
212 Main Street
Northampton, MA 01060
-1Y—/ 4
Date
TO B COMPLETED BY BOARD OF H
-Z9 f 70 Permit expires on:
Permi i sued (date)
A TI
101 (One year from date of issuance)
City of Northampton
BOARD OF HEALTH
PERMIT NUMBER: 2014-2
FEE $ 50.00
CHECK# 33729
CASH
This is to certify that Barrett Newsom (using driller Kirke Henshaw)
NAME
341 Audubon Rd, Leeds
ADDRESS
Is Hereby Granted a Permit to Install a
Private Drinking Well:
LOCATION: 341 Audubon Rd, Leeds
DAT Aril 29 , 2014
B:and of Health Director
This license is granted in conformity with the Statutes and ordinances relating
thereto and expires April 29,2015 unless sooner suspended or revoked.
DEPARTMENT OF ENVIRONMENTAL PROTECTION
Pursuant to the provisions of
Massachusetts General Laws Chapter 21G Section 20
Kirke Renshaw #196
is authorized to dig or drill all types of wells
in the Commonwealth of Massachusetts during the period
01/01/2014 to 12/31/2014
Commissioner/Designee
DETACH CERTIFICATE ABOVE ALONG PERFORATION
COMMONWEALTH OF MASSACHUSETTS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
COMMONWEALTH OF MASSACHUSETTS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
WELL DRILLERS CERTIFICATION PROGRAM
114991914611oanse'0
rC ike iI¢n5}aw
CERT.NO
196 01 @142014
EXPIRES
12/31/2014
SIGNED.
J
CAREFULLY PUNCH OUT CARD ABOVE AND PLACE IN YOUR WALLET
FAX
Fax to number:
To:
Attention:
Date:
From:
Number of Pages:
Additional
comments:
CITY OF NORTHAMPTON
NORTHAMPTON
BOARD OF HEALTH
yl Z9(o
IM7OI4
3
t x Al QgAAeA- e -ApN vidANIA
hp_ I rC thou -us_D
NORTHAMPTON BOARD OF HEALTH
212 Main Street— Municipal Building
Northampton, MA 01060-3191
Phone: 413-587-1214
Fax: 413587-1221