573 Well Construction Permit 2018 BOARD OF HEALTH
City of Northampton
APPLICATION FOR A WELL CONSTRUCTION PERMIT
Welt Permit Number0/0
/ir (TO BE ASSIGNED BY BOARD OF HEALTH) Fee$50.00
This application must be accompanied by a scaled plot plan, produced by a cMl 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.
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Owner's Name Date `
Street Address Telephone Number
A) e ref 4 wt.," .) h1 � el OG.
City, State,Zip Code
Location of Proposed Well Tax Map# Parcel#
(if different from address)
See ' ' / g
Well Driller(submit evidence of valid state registration) Con-; ation o ' ' i+ A % ,ipg
al
(SLa alley gl10 I. r. onma.gov)
For new construction:
Septic system plan complies with Title 5: yes( )no( ) n/a( )
Septic system plan shows location of well: yes( ) no( ) n/a( )
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For new, repair or location to leach field, septic tank or city sewer:
• ed well co struction plan has been submitted:yes( )no( ) n/a( )
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Si=a Shire of Ai s licant Date
Please Mail Application to:
Northampton Board of Health
212 Main Street
Northampton, MA 01060
TOB CO PLETED BY BOARD OF HE L H
'7 7 /,8 Permit expires on: 7 ,17/`f (One year from date of issuance)
Per ' issu d(date)
NORTHAMPTON BOARD OF HEALTH 1 ,
212 MAIN STREET G' ,: FILE COPY
NORTHAMPTON, MA 01060
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