127 CANAL STREET - WELL -«..- - ,...._.o.,r...S a..n .... ..
CITY OF SAL"EWMASSACHUSETTS w TM
BOARD OF HEALTH
5f 120 WASHINGTON STREET, 4TH FLOOR -
LSALEM, MA 01970
TEL. 978-741-1800
FAX 978-745-0343 _
STANLEY J. LISOVICZ, JR. JOANNE SCOTT, MPH, RS, CHO
MAYOR HEALTH AGENT
WELL CONSTRUCTION PERMIT
Location: 127 Canal Street
Owner: Anthony Gattineri
Address: 127 Canal Street, Salem, MA
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#: 004-05
Date Issued: 4/19/2005
(Monitoring Wells) (TED Inc. — Reg. #560)
HEALTH AGENT
CITY OF SALEM, MASSACHUSETTS
BOARD OF HEALTH
120 WASHINGTON STREET, 4TH FLOOR
SALEM, MA 01970
TEL. 978.741-1800
Fax 978.745.0343p �C C )'t��G
STANLEY J. USOVICZ, JR, JOANNE SCOTT, MPH, RS, CHO Ikr�+- ll Il`r�{VU II ii Illt
MAYOR HEALTH AGENT
APR0 12005
CITY OF SALEM
BOARD OF HEALTH
Well Construction Permit p
Iication
Date: S Fee: $100. Check payable to the City Of Salem (no cash)
Location:_ Ia? 7 Coln cL SfR�e f " Salem, MA, 01970
Owner. A,; +to 'nL
Address Tel. /9'?.0 37S�SS7y
Type of well: mles'," Well use: r tj CL
Well Contractor: A£W we S Pump Co ctor: lidf//ih✓
Address: 9a6 S% e4 l S;N s�h'F airs Address: /Sri /17a-'� Srt
Phone: /fLv-G371'3Soo Phone:
Reg. #: jo
Have abutters been notified? (y)/ How? leIle-a S
In the space provided below(oron back)show the location of the proposed well In relation to+
existing or proposed above or below ground structures. A description of visible prior and current
land use within (200) feet of the proposed well location, which represent a potential source of
contamination. G
y� t';G�h
gjq
I Twet/
S'+
7hare is no fee for monitoring wells but a permit is required for installation /
B.O.H. use only. Check W. Check date:(3 0 j— Permit o: ere 7
Well const permit appl revicea 1112M2
'
C17Y OF SALEMBDAfl00FMEA1.tN
;,aluml Massacncsatts 01970 120 Washnlgloa Srrcn e'4 llnol
(9'18)'tai-11401
hex:(9781 70 0141
joANNI:3C.u11.MVH.Hti ::uCi
I ICALYN'rYr9Mt
t3N ap/ate uBF1Y�erti�"icat�P-B!'c�n
1 Ce1uTCatetiY
it "rd of Health shall
water supplY• A Water
�,�Issuance of a Water be used as a drinking 11 prior to the
vate*61 may of apn 0 tNe P
certify that rtica must be Issued for the u riot to the tssuana:
supply rtc penrlttfor an exlstul9 struchue Of by the well.
159uanCe of an°�� y nIt j tion whit l iaio be s
o{2 building pelt for new co th to obtain a water Supply
7aretoilowing�t be submitted to thR Board of Neal
Certificate'.
'Copy of the Well ronstruc*tion Permit an `,8 required by the OE'
*copy of the water Well Completion"13
Deaf Water Res"
(313 GSR 3 00)
-Copy of the Purnping Test Report
'Copy of thewater Quay RePorty ._ -------' '
•- --- ------
Salem,tOA-
LocationDf ^�tl —�J
'- Tel �F9-
owner of properry r t k ---
pwna>'s address. ��
Date
permit#
g.011'use only
b,T:d £h£05b48L6T:01 :WONd t1S0.2T 6661-91-Ndf
JAN-16-1999 12:05A FROM: TO:19787450343 P:2,4
GIYIr OF SAtXM1.IVFASSACHUS=' '
BOARD OF HEAL"
120 VN SjAINOTON S"E%T.ETN f600n
SALE", MA 01870
Teff 47e-761.111QQ
FAx 978-745-0945
JOANNL Scaly.-moll-0.5.4"0
STANIEr UROVMT,JN. �IIAU'M A4 v'NT
N1nYOn
Salem BOard of Heath P T °
r
Name of well OWW .
wPu IMAhnn(referenced to»dealt tWo permanent structures or l8ndma*5)
.�--
Date pumping fest was pel{Omled:
LAW
Depth 3t which pump was$et for the test:------ 1�
Locetion of the disdv'7rge lino'
— =- `—
Staticwater lercl immedlatebf Wore pump!P9�' .. ��•
��(h (it app(ioat>te,that the discharge late changed)
Discher"late: �
pumping Waftf tcveig and respective times after pumping commenoed:
Maximum drawdown duffing the test
Dwation ut lest. s)pumping t4 duringwhich m urcments"e'u caken�—
b)rewvCty �^ —
__...--�— cgveU�alimcess3donofpumping:,_1 — i --
Recovery Water levels olid respe
Reference point used foral.measurements
please fill out form completely and return to the Salem gog fd of HOaith
along w►tlr Nle WatEF
Vey Compt`etwn Repan• Pump test report is a
suing a Water Well 5upplY Cerdfrcate.
requirement Prior to is
I
JAN-16-1999 12:05A FROM: TO:197e7450343 P:3,4
CITY Or SALEM, MASSAOHUSt—r t r3
eoARu civ HEALTK
120 WAaNIN11TON STREET, 4111 FLOOR
SAL.0 . 14A 0tB-7U.,
TEL. 978-741.1600
(b rAx 978-74¢{7343
GTANL9� VI,Mlc7..la- JOANNE Scul'1', Mrij. RS. C710
MAYOR M1a ALC" AGENT,
Salam Board of Heahh PumDlnf�Tes RReport
Name of well owrw.' .fjjjkV.0rVA' `Address-.' °1 �
V
BNeh."-Autm(reterenccd to adesst two permanent stnuyures or tandmatks)..
. ,._ 'rZ�1f►�'2_—
Date pumping lest was performed
Depth at which pump was set fbr the test
Location of thedlsdurgo-llae
Static water levetimmedlately,6etore pumping commenced: —
Dischene rate ►C] OWN (if applicable thrmthe.discharge rate changed)
Pumping water levels and respecbve rimes eller pumping wnuneneed. I so J�4—
Maximum drawdown during the test ' --—
Duration of test a)purlVirt9 time' V
b)recovery lime d0ri710 which meaautements were taken
Recovery water Nv¢Is andrespective.dmes after cessation of pumpiRg.
Reference point used for ah measurements: ... ...
Please rill out form wmpl#Wy and return to the Salem Board of Heald,
aro ng withter Well Completion Report Pump test roport is a
the Water P
requirement prior to issuing 0 WaterWell-SuP#Y Ce&,"cjAe-
JAN-16-1999 12:05A FROM: TO:19787450343 P:4,4
i
CITY OF SALEM BOARD OF HEALTH
Salem; Me333chusettS-01970,
JUPNNk$CQ)I,MMM,N1.faln
120 Washington Stmct 4's floor
ltEAlttt AGENT 7-els(979),741-IM
f8x:(978)741 Dt43
Well Water Supply Certificate Application
The issuance of a Water Supply Certificate by the Board of Health shall
certify that the private well may be used as a ddnki%water supply. A Waley
Supply Certificate must be issued for the use of a private well prior to the
Issuance of an occupancy permit for an existing.sttucUrte or.prict to-the issuartw,
of a building permit for new construction which is to be served by the well-
The following must be submitted to,the Board-of Health to obtain a Water Supply
Certificate :
'copy of the Well Construction Permit
'copy of the Water Welt Completion Report ;mrequired by the DEM_
Office of water Resources(313 CMR 3.00)
'copy of the.Pumping Test.Report
'Copy of the Water Quality Report
- t.oration-af_welk. 1�{a-. 0--nCt1Salem,.MA..
Owner of rope on a PLTot,
Owner's address: A,{��a! .-154- Ti� ccs,
Date:�j
- ---------------------
B 0 H use only Permii #