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					                                              Department of Inspectional Services
                                                  Worcester, Massachusetts                                   John R. Kelly
                                                                                                             Acting Building Commissioner
                                              Air, Water and Hazardous Material
Joseph R. Mikielian                                                                                          Amanda M. Wilson, Director
Commissioner                                                                                                 Housing/Health Inspections


             Fee: $220.00
                                  APPLICATION TO CONSTRUCT A WATER WELL

             Application is hereby made for a permit to construct a Private Water Well at:

             ________________________________________________________ ______________
             Location/address                                            lot number
             Owner:              ____________________________________________________________
             Address:            ____________________________________________________________
             E-mail address: __________________________________________________________
             Installer:          ____________________________________________________________
             Address:            ____________________________________________________________
             Type of well: ____________________________________________________________
             Distance from public way:               ________________________________________________
             Distance from sewage septic tank:                 __________________________________________
             Distance from sewage disposal field: __________________________________________
             Distance from property line: ________________________________________________
             Agreement:

             The undersigned agrees to construct the aforesaid water well in accordance with the
             provisions of the Private Well Regulations promulgated by the Board of Health,
             Worcester, MA which went into effect July 1, 1988, and further agrees not to utilize the
             water from said well for human consumption until a Certificate of Compliance has been
             issued by the Board of Health.


             Applicant’s signature                                                             Date

             Application approved by:                ______________________________ Date: ____________

             Application disapproved for the following
             reason(s):________________________________________________________________
             ________________________________________________________________________
             Permit Number: ___________________                          Date Issued: _________________________
                 25 Meade Street, Worcester, MA 01610 Phone: 508-799-8576 Fax: 508-799-8488 e-mail: inspections@ci.worcester.ma.us


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