308 Well 2011 BOARD OF HEALTH
City of Northampton
APPLICATION` FOR A WELL CONSTRUCTION PERMIT
Well Permit Number0&0I I-0 J (TO BE ASSIGNED BY BOARD OF HEALTH) 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, 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(X) or repair ( ) a private well.
Patrick Melnik, Jr. 12/9/2011
Owner's Name Date
110 King Street (413)584-6750
Street Address Telephone Number
Northampton, MA 01060
City, State,Zip Code
308 Chesterfield Road, Northampton, MA 01053 15B 001
Location of Proposed Well Tax Map # Parcel #
(if different from address)
f/e.,f4a v 4reY 0-: 7/4y
Well Driller(submit evidence of valid (tate registration)
For new construction:
Septic system plan complies with Title 5: yes ( ) no ( ) n/a(X)
Septic system plan shows location of well: yes ( ) no ( ) n/a(X)
For new, repair or location to leach field, septic tank or city sewer:
A scaled well construction plan has been submitted:yes (X) no ( ) n/a( )
417/
Sign. Applicant Dat
2/
,
PleaseMail Application to:
Northampton Board of Health
212 Main Street
Northampton, MA 01060
TO BEOMPLETED BY BOARD OF HE1A TH
2-1c 2e4\ Permit expires on: I I S�w1240ne year from date of issuance)
Permi issued (date) r
City of Northampton
BOARD OF HEALTH
PERMIT NUMBER: 2FmI1 - n5 FEE $
CHECK# 5'41
J/J� X71 CASH
This is to certify that f a gt c t Ne
NAME
H O L'.t .) S1' O IOU O
ADDRESS
Is Hereby Granted a Permit to Install an
Individual Private Drinking Well:
LOCATION: 3O8 CktSttch E(-e2 d
DATE: Dtc . I c , 20 1 A
Boar t D' ect yw/CO
This license is granted in confer-114withthe Statutes and ordinances relating
thereto and expires I 7_ I1S) 2.01 Z unless sooner suspended
or revoked.