28 Application & Well Permit BOARD OF HEALTH
City of Northampton
APPLICATION FOR A WELL CONSTRUCTION PERMIT
Well PermitNumberad/u-? (to be assigned by board of health( Fee: $ sC
Fee: 850.00 minimum for first well
825.00 for each additional well
Total# of Well(s)
This application must be accompanied by a scaled plot plan.produced by a civil engineer or
registered sanitarian showing adherence to the Underground Injection Control (UK')
requirements.
Application is hereby made to construct Did or repair( )a well.
�hgv7k 7� n,oetko Ir / / Y / 10
Owner's Name Date
28 ea yuenj imcfack H13. 58G. 3908
Street Address Telephone Number
prom-4,4.-P 4,(1 Mme# to ti)
City, State, Zip Code
Location of Proposed Well(s)
(longitude and latitude)
AWL/a_ alie#0Lifith)
Signature of App cant
Please Mail Application to:
Northampton Board of Health
212 Main Street
Northampton, MA 01060
Tax Map# Parcel #
/7— - %O
Date
TO BE COMPLETED BY BOARD OF HEALTH
11 0 '0
Permit iss ed( te)
BOARD OF HEALTH
City of Northampton
APPLICATION FOR A WELL CONSTRUCTION PERMIT
Vell Permit Number (TO BE ASSIGHED BY BOARD OF HEALTH) Fee $50.00
this application must be accompanied by a scaled plot plan, produced by a civil engineer or registered
anitarian showing the minimum distances required in Title 5 of the State Environmental Code. For new
onstruction, requiring a septic system, the septic system plan submitted for the property in compliance
rith Title 5 requirements will be acceptable if the proposed well location is included.
■pplication is hereby made to construct( ) or repair( ) a private well.
)wner's Name Date
treet Address Telephone Number
)ity, State, Zip Code
.ocation of Proposed Well Tax Map S
if different from address)
Parcel ft
\JASNU✓6u;_ t c, 44/ 46�'1 hos-r(2_ F w� L
Vell Driller(submit evidence of valid state registration)
or new construction:
Septic system plan complies with Title 5:
Septic system plan shows location of well:
yes (
yes (
ror new, repair or location to leach field, septic tank
A scaled well construction plan has been submitted:yes (
) no ( ) n/a ( )
)no ( ) n/a ( )
or city sewer:
) no ( ) n/aO
signature of Applicant Date
'lease Mail Application to:
Jorthampton Board of Health
12 Main Street
iorthampton, MA 01060
CO BE COMPLETED BY BOARD OF HEALTH
Permit expires on: (One year from date of issuance)
'ermit issued (date)
NUMBER
oio -8
City of Northampton
FEE $
BOARD OF HEALTH SO
This is to certify that
I /Griq Yu moL2ko
O
;0 i?orvitroy
NAME 11
eCcc ,
J
For CO Q Il
ADDRESS
Is hereby granted a
Permit
Co r s4r„Lon ( ; re;ckcA-4'coA)
This license is granted in conformity with the Statutes and ordinances relating
thereto and expires // // / ao/i unless sooner suspended
or revoked.
/
, 20 /0
Bo Health