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1089 Application & Permit/Certificate for a Well City of Northampton BOARD OF HEALTH PERMIT NUMBER: 2016-1089-W FEE $ 50.00-Paid CHECK# CASH This is to certify that Ryan Wraeg NAME PO Box 59, Rindge,NH 03461 ADDRESS Is Hereby Granted a Permit to Install a Private Drinking Well: LOCATION: 1089 Westhampton Road, Florence. MA 01062 DATE:December 9, 2016 \\\ l�eetec/ Board of Health Dh This license is granted in conformity with the Statutes and ordinances relating thereto and expires December 31,2016 unless sooner suspended or revoked. BOARD OF HEALTH City of Northampton APPLICATION FOR A WELL CONSTRUCTION PERMIT V rj.l Permit Number (TO BE ASSIGNED BY BOARD OF HEALTH) Fee$50.00 pwtd` application must be accompanied by a scaled plot plan, produced by a civil engineer or registered tarian showing the minimum distances required in Title 5 of the State Environmental Code. For an new struction, requiring a septic system, the septic system plan submitted for the property n Title 5 requirements will be acceptable if the proposed well location is included. or repair( )a private well. )lication is hereby made to construct ra ner /0 eet Address D L /3 1427 cs7S Telephone Number :y, Sta cation of Proposed Well different from address) ell G fl VW/6/ er(submit eJ it .T; Tax Map of valid state registration) or new construction: Septic system plan complies with Title 5: Septic system plan shows location of well: 6? Parcel # I%1✓ C.nservation Commi Approval (SLaV allev(rr�northamotonma Gov) yes IK) no( ) n/a( ) yest)no ( ) n/a() 'or new, repair or location to leach field, septic tank or city sewer: A scaled well construction plan has been submitted:yes ( )no( ) n/a( ) ature of • pplican Please Mail Application to: Northampton Board of Health 212 Main Street Northampton, MA 01060 ate Date T BE C MPLETED BY BOARD OF HE /,y (One year from date of issuance) �, r , 2C/ Permit expires on:/ Permit issued (date) DEPARTMENT OF ENVIRONMENTAL PROTECTION L d co III 1f CJSETTS WELL DR'L if '+-� N�p,SSA LES CERTIFICATE S Pursuant to the provisions of Massachusetts General Laws Chapter 21G Section 20 N Ryan Wragg #919 is authorized to dig or drill all types of wells in the Commonwealth of Massachusetts during the period 01/01/2016 to 12/31/2016 Commissioner/Designee