HomeMy WebLinkAbout0035 BRETWOOD LANE - Health (2) �513r�-1-�.�� 1�+��-
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No.-- ----- - Fee
BOARD OF HEALTH
TOWN OF BARNSTABLE
Application for Vell Con5tructioni3ermit
Application is here made for a permit to Construct (-I, Alter ( ), or Repair ( )an individual Well at:b
Location — Address Assessors Map and Parcel
-`---------M e-F L -------------------- -----
1 ! Owner Address
Installer Driller f Address
Type of Building
Dwelling------------------------------------------------------------------
Other - Type of Building ----------- No. of Persons--------------------------
Type of Well Ca acit ----- -- -
Purpose of Well---ll� ' G-C,I;cw-- - ---- --
Agreement:
The undersigned agrees to install the aforedescribed individual well in accordance with the provisions of The
Town of Barnstable Board of Health Private Well Protection Regulation - The undersigned further agrees not to
place the well in operation until a Certificate .of ompliance has been issued by the Board of Health.
Signed -- ---- - -----------
date
Application Approved By ---� Ll -�'-'��-�J - -- -— - ' /
date
Application Disapproved for the following reasons:---------------------------------------------------------------------------
-------------------------------- --- -----------
- ----------------------------------------
date
PermitNo. --------- - -----—-- — -- Issued----------------------------------------------------------------
date
BOARD OF HEALTH
TOWN OF BARNSTABLE
Certificate Of Compliance
THIS IS TO CERTIFY, Th the Individual W 11�Constructed ( -1, Altered ( ), or Repaired ( )
bY----------- w - --- -- - ---- - --
at------ ----------------
�'_—!�_!G'_ �JoU�-- L h� �e w 's1_L�1 P-------------------------------------------------------
has been installed in accordance with the provisions of the Town of Barnstable Board of Health Private Well Protection�c
Regulation as described in the application for Well Construction Permit No.l���----- ?Uated _"`_---
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL
SYSTEM WILL FUNCTION SATISFACTORY.
DATE------------------—- --------------------------- -- Inspector--------------------------------------------- - - ----------
�.�r-�Y'.'�i���t*�f"`T '�"'';.�-�'�[°�,�s6�,-,�,,�.���it�"lYs�^t�•�T'I�yr nSi .,�,Ak�r r"..'"�i�rr:i�~' '�''�^K?"""'�'r"1-rcl; "i''M`i�N�3t`�2e►Arrr.F''�,�.>/ter-'"'j}r�i �,.A�r., :` ..
__------- Q - ---No.J � �' Fee-- - -
�a BOARD OF HEALTH
TOWN- OF ,'BARNSTABLE
�pp[icatfon,�or�elC� �Cott�truction�ertnit
Applicati is hereb' 'made for a permit)to.Construct (�, Alter ( );'or Repair(: )an individual Well.at:
k t Location Address Assessors Map and Parcel
' Owner Address
&JJ9-
Installer - Driller Address
Type oftBuilding .
Dwelling-------- -----------------------------------------=----------
Other - Type of Building--------------- ------------- '' No. of Persons---------- ------------____ -
---Type of Well- r I- - -- -=- --------------- CapacitY- - ------------
- ----
- - - -
Purpose of Well----
Agreement:
The undersigned agrees tginstall the'aforedescribed individual well in accordance with the provisions of The
Town of Barnstable Board of Health Private Well Protection Regulation - The undersigned further agrees not to
`place the well in'.operation.until a,Certificate .of Complianc has been issued by the Board of Health.
Signed -------�------------------ =- 2YZ/_ZA
date
Application Approved.BY' -- -- --
Ad� % date
Application Disapproved 'for the following reasons:..-- — _--------=-------------------—--------___--------
__-__�___�_-__-____
- - -- ---- -— ------- ' - ----- - - -------------------------------------------------------------------------
date
Permit.No. --------------- Issued-------------------------------------------- --- ---------
date
BOARD OF HEALTH
TOWN OF BAR,NSTABLE
Certificate ®f Compliance
THIS IS TO CERTIFY That the Individual Well Constructed ( �J Altered ( ) or Repaired ( )
by --------- w P //-- !L-�I` - ---------------------- -- -- -- --------- ------ -----------
I -
sl
to ler
at - _ /PL`?�� ��a— �� �'-"�� ----- --------- -------- ----- ----
has -
- Ybeeri installed in:accordance with the provisions of the Town of Barnstable Board of.Health Private Well Protection
Regulation as described in the application for Well Construction Permit No. ated ��- - 4���
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL
SYSTEM WILL FUNCTION SATISFACTORY.
DATE- - - - - - -- Inspector--- ---------------------- ------------------- ------------- -
BOARD OF HEALTH
TOWN OF - BARNSTABLE
Vell Con5truct ion i3ermit
No. Fee------ v� --------
�'Y < �,�
Permission is hereby granted---a A==�-��'`'� � f-��—�Jr` �[
----- -----------------------------
to Construct ( -),.Alter { ), or Repair (' ) an Individual.Wlell at
No. ---------------------- -----------------------------------
street
as shown on the application for a Well Construction Permit
No; -------- ------- ----------- Dated-----------
- ------ -
/� Board of Health
DATE --