45-49 CONGRESS STREET APPLICATION FOR MONITORING WELLS 3-22-22 -co
CITY Or SALEM, IVIASSACHUSETTS
BOARD or{HEALTH
98 WASHINGTON STREET
�3RD FLOOR Pub&Health
Prevent.Promote.Protect.
TBL. (978) 741-1800
K \1BERLEY DRISCOLL health salem.com
D AVID GRr.t�Nr�A �t
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Well Construction Permit Application
Fee: $180.00 Check payable to the City of Salem (no cash)
- No charge for monitoring wells -
Date:
Location: Salem, MA 01970
Owner:
Address
Telephone
Email
Type of Well: Well use:
Well Contractor: SOS; f;nC Pump Contractor:
Address: PO-[() 51 A/y::4 Address:
Phone: g-78_ Lfzz--aco Phone:
Reg.
Have abutters been notified? (y) How?
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!n 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.
Note: There is no fee for monitoring wells, but a permit is required for installation.
B_o.H. use only Check#: Check date: Permit#: