1526 Application & Permit for Well Construction City of Northampton
BOARD OF HEALTH
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PERMIT NUMBER: 7 -0 / FEE $
CHECK#6131
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This is to certify that /-ant. 7c e ,
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NAME
6/+ms's- &Ai — %9�DRE�-r -tsi-.e.�. c d Paz
Is Hereby Granted a Permit to Install an Individual
Private Drinking Well:
LOCATION: / fa& LU .s�Y/,‘„r. /6 ,-4,
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This license is granted in conformity with the Statutes and/or Ordinances relating
thereto and expires on ,200 unless sooner
suspended or revoked.
L :k%21-
DATE �n
:•_�"'y��� ,2002
rnest J_Mathieu,RS.,M.S.,C.H.O. v
Director of Public Health
Northampton Board of Health
DBA MCCUTCHEON CONSTRUCTION
PAUL C. MCCUTCHEON
77 FOREST GLEN DR.
FLORENCE,MA 01062
53-7168-2118
r 6930
11 �1 c'
,L, _ II $
, fop
A R,
FLORENCE SAVINGS BAN
85 MAIN STREET
FLORENCE,MA 01062
Far -
1: 2L187L6881: 02 23 810 185 6930
City of Northampton
Board of Health
Well Permit Number / Fee $ 613 U a
APPLICATION FOR A WELL CONSTRUCTION PERMIT
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.
Apptr�ation is hereby madeeCtoo construct( ) or repair( ) a private well. H,..'k Date
Odner's Name
Street Address
rmui cece
Telephone Number
/1,4- 01060
City, State, ZZip Coe
ICz6 Lf 1/ t-/
Location of Proposed Well Tax Map#
Parcel #
(if different from address)
For repair or location with city sewer:
Scaled well construction plan has been submitted: yes no ( ) n/a( )
For new construction:
Septicsystem plan complies with Title 5: yes (»no ( ) n/a( )
Septic- st'm plan shows location of well: yes (ono ( ) n/a( )
d . z
Signatu e . rApplicant Date n —4117'i""
PernV
Permit expires one year from
date of issuance