231 Application for Well Permit 2013 BOARD OF HEALTH
City of Northampton
APPLICATION FOR A WELL CONSTRUCTION
rmit Number (TO BE ASSIGNED BY BOARD OF HEALTH) I4ee $50.00
placation must be accompanied by a scaled plot plan, produced by a civil engi er or registered
an showing the minimum distances required in Title 5 of the State E • tal Code. For new
ction, requiring a septic system, the septic system plan submitted for the property in compliance
e 5 requirements will be acceptable if the proposed well location is included.
[Lion is hereby made to construct( )or repair (C)a private well.
s ame
1/4-/Q-1,crRt
ess
cc■cv Nln
:ate, Zip Code
a\ (3
Date
(BSC- 35161
Telephone Number
m of Proposed Well
sent from address)
Tax Map q Parcel ti
k\tb\\\k
tiller(submit evidence of valid state registration)
ew construction:
Septic system plan complies with Title 5:
Septic system plan shows location of well:
Conservation Commission Approval
(SLaVallev( northamntonma.aov)
yes (n O o ( ) n/a(
yes ( no n/a( )
ew, repair or location to leach field, septk_tank oreify sewer:
A scaled well construction plan has been submitted:yes ( )no ( ) n/a ( )
t4 6(C
of Applicant
e Mail Application to:
tmpton Board of Health
ain Street
tmpton, MA 01060
,_a,\_ ,�
Date
t CO FLETED BY BOARD OF HE L H
5 Permit expires on:
issu d (date)
w! 4.51d1
(One year from date of issuance)