MONITORING WELL PERMIT IT� owl
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- TeL. 978-741-1800 !_S,!+
FAX 978-745-0343
Kimberley Driscoll WWW.SALEM.COM
Mayor JOANNE SCOTT, MPH, RS, CHO
HEALTH AGENT
WELL CONSTRUCTION PERMIT
Location: 118 Washington Street
Owner: RCG-LLC
Address: 17 Ivaloo Street, Suite 100
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#: 003-06
Date Issued: 4/26/06
(Monitoring Wells) (TED Inc. — Reg. #560)
HEALTH AGENT
APR-10-2006 11:37 FROM CER, INC. TO 19767450343 P.02
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CITY OF SALEM BOARD OF HCALTH
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Pax:(979)745 0)43
Well Construction Permit Application
Date: Old P& Pee' &' Check payable to the City of Salem(no cash(
Location: Salem. MA.. 01970
Owner; /Lem Addressi7rya!„os;Su.Kiav_Tei. 4.i9-C,zS
.$•[/Mer✓i!(.rr»>9 OZ/yj, .
Type of well: Awm"n�Well Use
.�7cay/r,.N�i.�
Well Contractor, ifE4j n&, Pump Contractor:
Address: /z-7z;wcusr
, a /3iy[�nao��9n Address:
Phone: �g.�gy_g8cz 4>/sq Phone:
Reg. ti:
Have abutters been notified? (yam/ How?
---------------------------• ---------------------------------------- -
LI tno cpaco Prowacd bolow(or on back)ZPOw(ho location or rho proposed welt in relation to. .
elis(ing orproposed above orbetow ground structures. Adescription orvisibre prior and cunenl
land use w((h(n(200)leer Or the proposed Well location, which repro8eW a potential sJurce Or
contamination,
_---------------------------------• - - _
B. use only, Check A.
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