| Town of Sunderland |
| Board of Health 12 School Street Sunderland, MA 01375 Phone:
413.665.1441
Fax: 413.665.1446 |
FEE: $75
WELL PERMIT
Application for Well Drilling/Well Construction/Well Destruction Permit
Date of Application: ______________________________
Inspection Date: ______________________________
Name of Applicant: _______________________________ Phone: ______________
Name of Property Owner: ________________________________________________
Map & Plot Number/Address_________________________________________________________
Contractor Employed & License #: __________________________________________
_______________________________________________________________________
Laboratory/Engineer to do Water Testing: _____________________________________
New Construction/New Dwelling New Construction/Old Dwelling
Repair of Existing System Destruction of Well
Size of Lot: _____________________ Resident within 200 feet of work? ___________
List distances of all other wells, subsurface fuel storage tanks or septic systems within 200 feet ________________________________________________________________
_______________________________________________________________________
Approved: _____________________________________
Board of Health Agent / Date