245 DERBY ST � 5" - v? r-3 ST•
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FAX 978-745-0343
Kimberley Driscoll www.SALEM.COM
Mayor JOANNE SGOTL MPH, RS, CHO
HEALTH AGENT
WELL CONSTRUCTION PERMIT
Location: 245 Derby Street (South Harbor Garage)
Owner: City of Salem
Address: 120 Washington Street
This permit is granted in conformity with the statutes and ordinances relating to well
permits.
Well Construction permits are non-transferable.
This permit shall be on site at all times that work is taking place. Permit shall expire one
(1) year from the date of issuance unless revoked from cause.
This permit does not constitute a Water Supply Certificate.
Permit#: 001-07
Date Issued: 3/28/07
(Monitoring Wells) (TED Inc. — Reg. #560)
HEALTH AGENT
CITY OF SALEMt MASSACHUSETTS
BOARD-OF HEALTH
120 WASHINGTON STREET, 4TR-FLOOR
R
SALEM, MA-01970
TEL. 978=74 T 1800
FAX 9-78-745-0343
STANLEY J. USOVICZ, JR. JOANNE SCOTT, MPH, RS, CHO
MAYOR HEALTH AGENT
Welt Construction-Permit ApRUcat!
Date: '3 I 0 Fee $100. Check payable to the-City of Salem (no cash)
Location: A Salem, Wk 01970
O _Address_1 12Tel. ' 9�K-(A-5685
Type-of well: Mb r r U Well use: u
Well Contractor: Gaol x� Ex� � Pump.Contractor:
Address: 4 bt erwctA Dr. 44olk)PV� 07.056 Address:
Phone: Sass_3$9-yv 3 y Phone:
Reg. #:
Have abutters been notified? (y)_ Howl I� 1 A Cavo W/ arinc deo
------------------- -------------------------------- —_ -- - ------
ln the space provided below(or on bac4 show the location of the proposed well in relation to
existing or proposed above-or below ground structures_ Adescription of visible prior and current
land use within (200}feet of the proposed welllocation, which represent apotential source of
contamination. �` UU ��
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There is no fee for monitoring wells but a permit is required for installation:
B.O.H. use only. Check#: Check date:^ _ Permit#:
Well const permft appl revised tt125/02