377 Application for Well Permit & Permit City of Northampton
Board of Health
Well Permit Number 6 -6
Fee s-15- ,
APPLICATION FOR A WELL CONSTRUCTION PERMIT
This 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 construction, requiring a septic system,
the septic system plan submitted for the property in compliance with Title 5
requirements will be acceptable if the proposed well location is included.
Application is hereby made to construct( )or repair( ) a private well.
i 1V.1(SS(ti' 1 ImY ) Sf-I.1moor Date of rig , ri(p o
Owner's Name
CIS VCrnl>n (S)1(0—4-
Street Address
600A u4 ,rna &i3- i
City, State, Zip Code
311 10( Last Niko
Location dPProposed Well
(if different from address)
elephone Number
Tax Map # Parcel #
For repair or location with city sewer:
Scaled well construction plan has been submitted: yes ( )no ( ) n/a( )
For new construction:
Septicsystem plan complies with Title 5: yes (l no ( ) n/a( )
Septicsyst m plan shows location of well: yes (`)no( ) Ma( )
ture of Applicant
Permit issued(date)
Date
Permit expires one year from
date of issuance
City of Northampton q
NUMBER ✓ � FEE $ '
°IOU -PE BOARD OF HEALTH 50,66
n 84/S' C/
This is to that / +
certify /
NAME (((///
/Pr i%n1141-073. 61-a-21-62164/ /)14- o/ 3ui
ADDRESS
Is hereby granted a
Permit
l M
For 3%'% r, . aif : U«'a2 +✓/i . _ 401 Mq-
I . i •wi a— ti a 1
This license is granted a conformity with the Statutes and ordinances relating
thereto 00
and expires ..:. ...� d unless sooner suspended
or revoked.
aiiirarwti 2006 �i s
Board of Health
8iclissa 3. tymiiur
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45 Brawn
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Your success es our business Insured FGICIGIFM .
Greenfield Savings Bank
Greenfi d Tumors Falls South Deerfield shelbume Falls l
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