308 Well Construction 2016 •
BOARD OF HEALTH FILE COPY
City of Northampton
APPLICATION FOR A WELL CONSTRUCTION PERMIT
Well Permit Number (TO BE ASSIGNED BY BOARD OF HEALTH) Fee $50.00
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(4 or wir 4a private well.
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Owner's Name Dat
08 cwc-tea:,¢tJ 4K11 - ST,111 07
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Street Address 0o4• A )1 Telephone Number
Leak ,.,,A • 0, 10i-2 /
City, State, Zip Code
7 0 6 l/Ja.t dtictf, 4' / s- 12 SU
Location of Proposed Well Tax Map # Parcel #
(if different from address) pp 1
t'.til(< •t -1 lob-) tett ,,,)l 744.., (ARAN
Well Driller(submit evidence of valid state registration) Conservation Commission Approval
(SLaValley(o,northamptonma.eov)
For new construction:
Septic system plan complies with Title 5: yes (411) no ( ) n/a( )
Septic system plan shows location of well: yes (JO no ( ) n/a ( )
For new, repair or location to leach field, septic tank or city sewer: 11 r• r
A seal d well construction plan has been submitted:yes(9 no ( ) n/a( ) at fI L,,' If�Il�i;•L
Pi
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Signatur f Applicant Dat
Please Mail Application to:
Northampton Board of Health
212 Main Street
Northampton, MA 01060 /
aos comm.
TOS �E�C� PLETED BY BOARD OF HEQLT / 6eao/6
6a Permit expires oru6 fia% 7(One year from date of issuance)
P mit i sued (date)
OM. x n* x an u.
M=v yrs. ` cP
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= DEPARTMENT OF ENVIRONMENTAL PROTEC'1ION
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S�, SETTS WELL D�
p_ CERTIFICATE
I Pursuant to the provisions o
isif _
Massachusetts General Laws Chapter 21G Section 20
Kirke Henshaw #196•
it
is}; is authorized to dig or drill all types of we
C) in the Commonwealth of Massachusetts during the period
01/01/2016 to 12/31/2016
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Comnussioner/Designee
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City of Northampton
BOARD OF HEALTH
PERMIT NUMBER:joie
01 50.00
CHECK# fag
CASH y�
This is to certffy that /-/ , �/ " . / - ^t
NA
3D0st (16)4/74 , o•
ADDRESS
Is Hereby Granted a Permit to Install a
Private Drinking /Well:
LOCATION: , dejy,4el Pei
DATE: „211 O\
Board of Hea , Director
This license is granted in cont y with the Statutes and ordinances relating
thereto and expires 7 �/7 unless sooner suspended or
revoked.
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