249 Application for Permit & Certificate 2015 -,C3
.!`
FILE COPY
BOARD OF HEALTH
City of Northampton
APPLICATION FOR A WELL CONSTRUCTION PERMIT
Nell Permit Numberard/c7 f'/ (TO BE ASSIGNED BY BOARD OF HEALTH) Fee $50.00
his 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
:onstruction, requiring a septic system, the septic system plan submitted for the property in compliance
vith Title 5 requirements will be acceptable if the proposed well location is included.
\pplication is hereby made to construct ( ) or repair(y)a private well.
)A✓/n 8 ribtWAyCe✓oikrYcA7
owner's Name
Street Address
1/2";/A RAfriA MAss• o/oQs
2ity. State, Zip Code
SyLva7i t�IJ F/o egNcc"fig-
Location of Proposed Well
if different from address)
oi' y9 Sv/✓�T 2� F..6241k?ei
Well Driller(submit evidence of valid state registration)
Croke, _go-A0/6--
Date
fAAr'K CARZL7 -”
6o3-2/3- 75
Telephone Number
�atR o/Yoo/
Tax Map # • Parcel #
For new construction:
Septic system plan complies with Title 5:
Septic system plan shows location of well:
� J
C serration C. m� Approval
( aVallevitilnorthamptonma.cov)
yes (!) no( ) n/a( )
yes N) no ( ) n/a ( )
For new, repair or location to leach field, septic tank or city sewer:/
A scaled well construction plan has been submitted:yes( )no ( ) n/a(.d"
'A6c/r%a,cowHc
Signature of Applica1t
Please Mail Application to:
Northampton Board of Health
212 Main Street
Northampton, MA 01060
Date
JUrrlc- 4a/E
AM0WD
TO BE COMPLETED BY BOARD OF HE�11TH
�v i� a . 2C)5 Permit expires on: '
Permit is9ued (date) L/
/0/a5,,)
(One year from date of issuance)
00
;gat 42:yee.
OF EVVHNONMENTAL PROTECTION
' t
provisions of
assachus e fs 1`Bnei Laws Chapter 21G Section 20
i