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1387 Well Permit 2018 City of Northampton /° din Board of Health Well Permit Number Fee $ SU <,' 00 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. Application is hereby made to construct or repair ( )a private well. (741-CB Arno Al f/23fr Owner's Name Date /387 &EirrMAmpron/ RD- 113- 320 - D67/ Street Address Telephone Number /L)0R-rrf4 rnP ran. r MA • City, State,Zip Code 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: (d no plan complies with Title 5: yes (r4 nno ( ) n/a( ) Septies0ystem plan shows location of well: yes (l4J no( ) n/a O 2W Cfzto V/2-3//1 Signature of Applicant Date Permit issued(date) n' Permit expires one year from V -6 �,n ELL date of issuance Con fv c 0t at\ mit-aovv� 1413 S. 5-7406Zo A . ' ► ad—OW MADI&a? BOARD OF HEALTH COMMONWEALTH OF MASSACHUSETTS oP*"AM oM1 413-587-1214 CITY OF NORTHAMPTON if JOANNE LEVIN,M.D.CHAIR MASSACHUSETTS 01060 �^ ll,.f DONNA SALLOOM r OFFICE OF THE IP SUZANNE SMITH,M.D. ir o /i CYNTHIA A.SUPOIS,PhD BOARD OF HEALTH � :: WILLIAMS HARGRAVES 212 MAIN STREET ;10._,..Lr MERRIDITH O'LEARY,RS,DIRECTOR Wed Construction Permit No. BHP-2018-0155 License Fee: $50.00 Issue Date: 04/25/2018 1Pursuant to 313 C10,3.00 In accordance with Massachusetts Registered Weft Drillers relating thereto, installation for well construction types for both potable and non potable purposes, no person in the business of digging ordrilling shall construct a welt unless registered with the 'Department of EEnvironmental Management/Office of Water cT esources.This is to cert that the'Board of7Ieatth has this day permitted you for the below listed address for a welt installation. Connecticut Valley Artesian Well Co. Whose place of Business is: 58 Bond Avenue In East Longmeadow, AKA Type of business: Well Construction WellAddress: 1387 Westhampton Road, Northampton, MA 01060 Expires: 10/25/2018 Director of Public Health LICENSE MUST BE POSTED IN A CONSPICUOUS PLACE ON PREMISES