HomeMy WebLinkAbout1550 FALMOUTH ROAD/RTE 28 - Health �55D �aQmm� P�c9
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No. -_l_l�=�-_! �09 "T �1 �^ Fee--L-?) -
BOARD OF HEALTH
TOWN OF BARNSTABLE
Application for Vell ConQructionAermit
ED p
Application is hereby made for a permit to Construct ( ), Alter ( ), or Repair ( )an individual Well at:
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-------------------------------------------------------------------------------- ---------------------------------------------------------------------------
Location = Address Assessors Map and Parcel
Kv l( &.f,-r a j t'ut d w t C-Ptv-l�r -�1 g c e
- - ---- - --------------- -------- ----------------------------------------------------------
L Owner f Address
/1ILTLC (NG7i�— /'t^t Ltl �LG. 72 IS Sa fL'd Z� Ce �rvt �6Y
- - ---------------------------------------------------------------- ---------- - -----------------------------
Installer — Driller Address
Type of Building
Dwelling---------------------------------------------------------------
Other - Type of Building---CCr t y`g 7'��'a+ -1�� No. of Persons - -
ct
Type of Well- - --p l k -- - - - Capacity-----Z-`--- s "'�---------
-------
----------- ----
Purpose of Well--- ___ _ -
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 Compliance has been issued by the Board of Health.
Signed --
date c
Application Approved By ---► "- — ---------------
1 date
Application Disapproved for the following reasons:---------------------------------------------------------------------------------------------
---------------------------- - -- --------------------------
date
Permit No. --- = -—---------------- Issued---------- 9--5�---6---------------------------
date
BOARD OF HEALTH
TOWN OF BARNSTABLE
(Certificate Of (Compliance
THIS IS TO CERTIFY, That the Individual Well Constructed (>�-Altered ( ), or Repaired ( )
bY- --- - - - - -��-
--------------------
Installer
at- --- ------<--- — -------------------------------------------------------- - --- -
has been installed in accordant 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. /T6-----Q-,?-Dated---�L------
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL
SYSTEM WILL FUNCTION SATISFACTORY.
DATE- - -- ------ ------ Inspector--------------------------------------------------------------------------
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No. Fee- ------- -
BOARD OF HEALTH
TOWN - OF BARNSTABLE
a pplication Ar Melt Congtruction rrmit
Application is hereby made for a.permit to Construct ( ), Alter ( ), or Repair ( )an individual Well at:
Location - Address Assessors Map and Parcel
HJ 11 tly-fp'4 J if W''-F olV_rJr 4 C
- --- - - - - -- — —-
j Owner Address
ATLi -Agri C we`-L Do �l/ � t c 7 � �Y , ���l�rV r l/�
- - - -- ----------------- 9 =------------------------- - - -- - - --------- t
Installer - Driller Address /
Type of Building
II Dwelling ---------------------------------------------------------------- ry
Other - Type of Building----rr-------"T/`ry -la-WN No. of Persons----------------------------------:-----------------
r r -
0 i q
Type'of Well- - ---p/ ----- --- - -- - Capacity--- w 6 - - - - -— -=—
- - ---
Purpose of Well-------------�-------------- - ,
/i(K/ �Tl'N
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 Compliance has been issued by the Board of Health.
a
p.t.e
? 2, �$/`/
Signed - ---- -- T-----------------;------- -------�- -- - --
date cc
Application Approved By S�- ------------- - _ I___
- — - — date
Application Disapproved for the following reasons: —----- -------------------------------------------=------_--
-------------------------------------- -----------------------------------------------------------------------------------------------------------
date
Permit No.--- -�D -- - Issued ---- t --- -�-g-- --------
i -
date
BOARD OF HEALTH
w
TOWN OF BARNSTABLE 'y
C ertif rate 0f Compliance
THIS IS.TO CER I Y, That the Individual Well Constructed (�-•Altered ( ), or Repaired ( ) 1
bY- --- 'T't'Q - -` - -------- - - - -----------
Installer
at --- -- _--�� — --- --------------------------- ---------------------------------------------------- ---------
- L
has been 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.VY,6-- -6--)-Dated-- -- -�---'
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL
SYSTEM WILL FUNCTION SATISFACTORY.
DATE-------- ---------- - -- -- Inspector------------------------------------------—-----------------------------
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BOARD OF HEALTH
TOWN OF BARNSTABLE
Vell Con5truct ion Permit
No. --- Fee --
------
Permission is hereby granted----L('— ------- ----------------------------------------------------
to Construct ( X, Alter ( ), or Repair ( ) an Individual Well at:
No. - - - - - - -— --- ------- -------- ------ ----------------------- ----- - ----------- --------
-
Street
as shown on the application for a Well Construction Permit
j
No.- - -� -=-- ---- — -- - Dated -- -�- -�- `� -- ---------=--------
1 i
Board of Health
DATE