10 WYMAN AVENUE / b mw Acca t)c
Sar SeP��C Par 946K
CITY OF SALEM, MASSACHUSETTS
3 , BOARD OF HEALTH
j 120 WASHINGTON STREET, 4TH FLOOR
SALEM, MA 01970
TEL. 978-741-1800
FAx 978-745-0343
W W W.SALEM.COM
Kimberley Driscoll JOANNE SCOTT, MPH, RS, CHO
Mayor HEALTH AGENT
WELL CONSTRUCTION PERMIT
Location: 10 Wyman Avenue
Owner: John O'Leary
Address: 137 Fort Avenue, Salem, MA 01970
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#: 003-08
Date Issued: 4/10/2008
(Domestic Wells)
HEALTH AGENT
CITY OF SALEM, MASSACHUSETTS
BOARD OF HEALTH
R 120 WASHINGTON STREET, 4TH FLOOR
SALEM, MA 01970
TEL. 978-74 1-1800
nrrB - FAX 978-745-0343
KIMBERLEY DRISCOLL JSCOTT@SALEM.COM
MAYOR
JOANNE SCOTT
HEALTH AGENT
Well Construction Permit Application
Date:y-q-�g Fee: $180. Check payable to the City of Salem (no cash)
Location: 1 taiy�4-Lt DtZt ve) Salem, MA. 01970
Owner: -ToW Q'(,P-Ao-y Address 137 ger Ave Tel. 47?- 375- 3008
Type of well: 9ePrC0e-k Well use: Cb My r-n G
Well Contractor:ehgru.�es M• rao u.;" & =.K. Pump Contractor:
Address: t7_1 p-e f Sr hd xfo�a A44 Address:
Phone: q-t 8 _ gg-t- 2--s z,a Phone:
Reg. #: 3o S
Have abutters been notified? (y)v How? V'f�-1154L` y
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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 visible prior and current
land use within(200) feet of the proposed well location, which represent a potential source of
contamination. OSee #-7—1 A--r" eD I"L4/J
7-91 Lm(�-vv t r4rjD, pr-1 Ext ST- ,-/ �
f} T �JZMgrJ r e/LRA�e rt+ I J zd� r.
There is no fee for monitoring wells but a permit is required for installation.
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B.O.H. use only. Check#: � 1 Check date: 1 (� Permit#: b09-0�
Well const permit appi revised 11/25/02-