1387 Well Permit 2018 City of Northampton /° din
Board of Health
Well Permit Number Fee $ SU
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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
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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
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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