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
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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
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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
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Tax Map
of valid state registration)
or new construction:
Septic system plan complies with Title 5:
Septic system plan shows location of well:
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Parcel #
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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
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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