573 Well Permit 2018 FILE COPY -7-a/0-/z;
BOARD OF HEALTH v�'
City of Northampton it�rRS
APPLICATION FOR A WELL CONSTRUCTION PERMIT ( y/
Well Permit Number (TO BE ASSIGNED BY BOARD OF itekin) Fee $50.00
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, requking 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.
SenT ifi r r/e, —17,4,) .5 s ,t 9 i z=
Owner's Name Date
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Street Address Telephone Number
City, State,Zip Code
____SNah,e
Location of Proposed Well Tax Map# Parcel#
(if different from address) ,
see triR-ACtFI-62. g.12
Well Driller(submit evidence of valid state registration) Co t' s411.11
"ion Approval
(S .Vallev(dno .tonma.aov)
For new construction:
Septic system plan complies with Title 5: yes( )no( ) lila( )
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 •. struction plan has been submitted:yes( )no( ) n/a( )
I ✓ J�'.7 2k, 201%
Sitg - of A..licant Date
Please Mail Application to:
Northampton Board of Health
212 Main Street
Northampton,MA 01060
TO BE;C LETED BY BOARD OF HEALTH7//
7ff//; .;?CJS Permit expires on: 7,77 )y(One year from date of issuance)
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CEIUSETTS WELL DRIL.I,k, 0:
r=ctt CERTIFICATE
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I-, authorved to dm or drill all types of vyells
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BOARD OF HEALTH COMMONWEALTH OF MASSACHUSETTS
413-587-1214
CITY OF NORTHAMPTON
JOANNE LEVIN,M.D.,CHAIR MASSACHUSETTS 01060ti,i
DONNA SALLOOM OFFICE OF THE IiYAW/
P
SUZANNE SMITH,M.D. +
CYNTHIA A.SUPOIS,PhD BOARD OF HEALT
WILLIAMS HARCRAVES 212 MAIN STREET
MERRIDITH O'LEARY,R9,DIRECTOR
Weft Construction
Permit No.BHP-2018-0275 License Fee: $50.00
Issue Date: 07/27/2018
Pursuant to 313 CMR3.00 In accordance with Massachusetts 4WisteredWelf(Drillers
relating thereto, installation for well construction types for both potable and non-potable
purposes, no person in the business of digging or drilling shall construct a well unless registered
with the (Department of Environmental-Management/Office of Water Resources.This is to
cert that the Board of.7fealth has this day permitted you for the below fisted address fora
well'instatTation.
Henshaw Well Drilling
Whose place of business is:
130 Cummington Road W
In West C6esterfieg 9101
Type of business:
Well Construction
WeIlAddress:
573 Sylvestor Road, Northampton MA 01060
Expires:
07/27/2019 Director of Public Health
LICENSE MUST BE POSTED IN A CONSPICUOUS PLACE ON PREMISES