138 Application for a Well & Permit-2011 10:59 FROt:NDRTHRt9PTUN HERLTH D 4135871E21
TO:914132964565 P.1:4
BOARD OF HEALTH
City of Northampton
APPLICATION FOR A WELL CONSTRUCTION PERMIT
Nell Permit Number(`"0\-1IRO tie nssionEO SV BOARD OF HEALTH) Fee$50.00
"his application most be accompanied by a scaled plot plan, produced by a civil engineer or registered
anitarian showing the minimum distances required in Title 5 of the State Environmental Code. For new
:Gosh-notion, requiring a septic system, the septic system plan submitted for the property In compliance
villa Title 5 requirements will be acceptable if the proposed well location is included. �t
tpplicaiion is hereby mule to construct( or repair O a private well. �i De R iC*fl c.� ft�°^4t�
Ask � --)-Y- //
hwlcr's N e Date
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areet Address Telephone Number
Ne el-1-n wt c/ 04 e
Sty, State, Zip Code
S A✓lty
,ocalion of Proposed Well Tax Map H Parcel it
if different II wn address)
krFK ,C qe on.elrir.% /AC.
Veil Driller(submit evidence of valid state registration)
'or new construction:
Septic system plan complies with Title 5:
Septic system plan shows location of well:
Yes ( )n0( ) nlaO
yes( )no( ) n/a( )
or new, repair or location to leach field, septic tank or city sewer:
A scaled well construction plan has been submitted:yes ( )no( ) n/a( )
///M �' Al.
vulture of Alt'icant
lease Mail Application to:
or hampton Board of Health
12 Main Street
'orlhampton, MA 01.060
q-30-11
Date
ret
'OBE COMPLETED BY BOARD OF HEALTH
Permit expires on: _ (One year from date of issuance)
ermit issued (date)
*'• %---c -'t
City of Northampton
BOARD OF HEALTH
co
PERMIT NUMBER: COI ' 0 FEE $
CHECK# )475
CASH —
This is to certify that
138 Ri LULS— 2 I?
ADDRESS
Is Hereby Granted a Permit to Install an
Individual Private Irrigation Well:
LOCATION:
This license is granted
thereto and expires
or revoked.
nc
v
n'o
pity with the Statutes and ordinances relating
?CI a- unless sooner suspended
DEPARTMENT OF ENVIRONMENTAL PROTECTION
oSSACgUSETTS WELL DRjLLERs
CERTIFICATE
Pursuant to the provisions of
Massachusetts General Laws Chapter 21G Section 20
Expires Dec 31,2011
Kirke Henshaw #196
is authorized to dig or drill all types of wells
in the Commonwealth of Massachusetts during the period
Commissioner/Designee
N.