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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