62 JEFFERSON AVE �C'GG (02 J�FxE'iPSbx� A�
FEB-25-2005 12:00 SP INC 978 745 4881 P.01i01
CITY OF SALEM, MASSACHUSETTS
BOARD OF H@ALTH -
130 WoSHINOTQN+STREET. 4TH FLOOR
SAL@M, MA 01970
TEL. 978.74 1-11300
FAX 978.7AS-03A3
STANLEY J. USOVICZ, JR. JOANNE SCOTT, MPH, RS, CHO..
MAYOR HEALTH AGENT
Watt Construction Per Application
Date: L2 _ 5' Fee:. $1.00. Check payable to the City of Salem (no cash)
Location. G Z U 15FF6P001.l f!U E Salem, MA. 01970
Owner; O CG I Address Orn B Tel.
Typeofwell: Welluse: Sa..,_ple ot Co94noLa,.9q,&f-
Well Contractor. 7-40 S]'ti7G Pump.Gontradot�
Address: sp-ERtlitia Nib Address:
Phone: 917 S' yZ 2 oov,$' Phone:
Reg. #:
Have abutters been notified?000 (y)____ How?
In the space provided below(or on track)show the location of the proposed well In relation to
existing or proposed above.or below gMund structures. A description of wslote pnor and currenr
land use within(200)feet of the pnoposdd well'location,which represent a polentfal source of
Contamination. t
f3OA s C-A RS
6 Z.
71
� F 1R tJ71J A J
There is no tee for monitoring wefts but a permit is required for instalta#on
_.........._......._- _..
+ 9.O.H. use anty. Check E' Check-dater 'permit.#:_ "r
` ` .
'
well const uermn aopi rariscd Str25i02 '
A i
^1 TOTAL. PR01
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