203 Permit & Certificate for a Well 2012 DEPARTMENT OF ENVIRONMENTAL PROTECTION
osSACHUSETTS WELL DIULLERs
CERTIFICATE
Pursuant to the provisions of
Massachusetts General Laws Chapter 21G Sectiou 20
Kirke Henshaw #196
is authorized to dig or drill all types of wells
in the Commonwealth of Massachusetts during the period
Jan 01,2012 to Dec 31,2012
Commissioner/Designee
DETACH CERTIFICATE ABOVE ALONG PERFORATION
COMMONWEALTH OF MASSACHUSETTS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
COMMONWEALTH OF MASSACHUSETTS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
WELL DRILLERS CERTIFICATION PROGRAM
I@suek Ise to
Kit
EXPIRES
12/31/2012
SIGNED'.
l
CAREFULLY PUNCH OUT CARD ABOVE AND PLACE IN YOUR WALLET
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If
City of Northampton
BOARD OF HEALTH
PERMIT NUMBER: OI -01)
This is to certify that
FEES
CHECK# (DS 1
CASH
NAME
703 SYA19Dc - ftg d
ADDRESS
Is Hereby Granted a Permit to Install an
Individual Private Drinking Well:
LOCATION:
DATE:
This license is granted in conformity with the Statutes and ordinances relating
thereto and expires t 17.0 I ZOI5 unless sooner suspended
or revoked.