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RPR-27-2004 0942 SP INC 978 745 4881 P.01i02
`A CITY OF SALEM, MASSACHUSETTS
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BOARD-OF HEALTH120 WASHINGTON STREET, 4TH FLOOR
SALEM, MA O 1970TEL. 978.74 1-1800 FAX 978-745-0943 (I/l
STANLEY J. USOVICZ,.JR• JOANNE SCOTT, MPH, R5, CHO APR 2 7 2004
MAYOR HEALTH AGENT
CITY OF SALEM
BOARD OF HEALTH
Well Construction Permit Application
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Date: o17Dy Fee $100. Check payable to the.City of Salem (no cash)
Location: 2 I-6cff/W)LOGY Wo4Y Salem, MA. 01970
Owner: Address Af Al7e1.
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G u T A! �b irVG
Type of well: PVC Well use: RA ND Wfl ETR I S►O rQ
Well Contractor: KENNEO ORlLLI GPump Contractor:
Address: I-XO)fl NN. Address:
Phone: (;V! SW-1100 Phone:
Reg. #:
Have abutters been notified? (y)_ How? NO
In the space provided below(or on back)show the location of the proposed well in relation to
existing or proposed above or below ground structures. A description of viable prior and current
land use within (200)feet of the proposdd well location, which represent a potential source of
contamination
Uc t L o vl" a.Gro ss '4�-O rn sdJe-m GIQ s s Co.
�t°C oLi� ocG1n�� site- pkity% +bv- 10CATr0n$
There is no fee for monitoring wells but a permit Is required for installation.
B.O.H. use only. Check>r Check date: Permit
Wal[const permil app! revised 11125!02
RPR-27-2004 09:43 SP INC 978 745 4881 P.02i02
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