85 Private Well Application/Permit 2011 BOARD OF HEALTH
City of Northampton
APPLICATION FOR A WELL CONSTRUCTION PERMIT
Well Permit Numberaod- (to be assigned by board of health) Fee:$ >()
Fee: $50.00 minimum for first well
$25.00 for each additional well
Total#of Well(s) )
This application must be accompanied by a scaled plot plan,produced by a civil engineer or
registered sanitarian showing adherence to the Underground Injection Control(UIC)
requirements.
Application is hereby made to construct CO or repair( )a well.
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Owner's Name Da
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Street A dress Telephone Number
City,State,Zip Code
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Location of Proposed Well(s)
(longitude and latitude)
Signature of Applicar
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Please Mail Application to:
Northampton Board of Health
212 Main Street
Northampton,MA 01060
2a
Parcel#
Date
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TO BE COMPLETED BY BOARD OF HEALTH
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Permit iss ed( t )
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FAX
CITY OF NORTHAMPTON
NORTHAMPTON
BOARD OF HEALTH
Fax to number:
413-582-9368
To:
Mr. Mark Cavanaugh
Attention:
Date:
June 8, 2011
From:
Heather McBride
Number of Pages:
2
Additional
comments:
Happy Watering!
NORTHAMPTON BOARD OF HEALTH
212 Main Street— Municipal Building
Northampton, MA 01060-3191
Phone: 413-587-1214
Fax: 413-587-1221
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City of Northampton
BOARD OF HEALTH
PERMIT NUMBER: 2011-2
FEE S_50.00
CHECK# 85436
CASH
This is to certify that Florence Savings Bank
NAME
85 Main Street Florence, MA 01062
ADDRESS
Is Hereby Granted a Permit to Install an
Individual Private Irrigation Well:
LOCATION: Behind 69 Main Street Florence (see map in file)
DATE June 8
, 20 11
Board of Health Director
This license is granted in conformity with the Statutes and ordinances relating
thereto and expires June 8 2012 unless sooner suspended or revoked.