203 Application for Well Construction Permit 2012-2011 10:59 F43101001HRNPTON HEALTH 0 4135871221
T0:914132954565 P.114
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BOARD OF HEALTH
City of Northampton
APPLICATION FOR A WELL CONSTRUCTION PERMIT
ell Permit Number (TO OE ASSIGNED BV BOARD OF NEA4TH)
is application must be accompanied by a scaled plot plan, produced by a civil engineer or registered
nitadan showing the minimum distances required in Title 5 of the State Environmental Code. For new
r stmction, requiring a septic system, the septic system plan submitted for the property In compliance
h Title 5 requirements will be acceptable it the proposed well location is included,
ptication is hereby made to construct repair( )a private well.
Fee$50.00
Sosnni P, uJesi
ner's Name
V-1 Sy Luesre.e 12o
et Address
IOitenCP lh't R O1 O&Z_
,State,Zip Code
SfNxP
Date
')13- 586- 8305
Telephone Number
Mon of Proposed Well
iiffeerentt from address)
T 2
1e_e 2- (d if s -i a at) .DNC
Driller(submit evidence of valid state registration)
Tax Map# Parcel
new Construction;
Septic system plan complies with Title 5:
Septic system plan shows location ofwell
yes("l O &a( )
yes(✓jno ( ) n/a( )
new, repair or location to leach fold,septic tank or city sewer:
A scaled well construction plan has been submitted:yes( )no( ) n/a( )
112012612
e Mail Application to:
mpton Board of Health
sin Street
mpton, MA 01060
Date
E COMPLETED BY BOARD OF HEALTH
Permit expires On: (One year from date of issuance)
ssued (date)