HomeMy WebLinkAbout0240 FIVE CORNERS ROAD - Health (2) a QED viva.. comcr� Qk-�c
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,(r ASSESSORS MAP Na
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No. ----- / Fee------------ -
BOARD OF HEALTH
TOWN OF BARNSTABLE
App iration-*rlVell CowaruttionA3ermit
Application is hereby made for a permit to /Construct ( ✓f, Alter ( ), or Repair ( )an individual Well at:
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— — ——-—-— --- — -- -- — --
Location — Address Assessors Map and Parcel
-TQ -------------------------------------------------- �Y�:fv- � �s ----------���r�U�,'lG
caner / /f Address —
------------------------------- -
Installer — Driller .Address
Type of Building
Dwelling------------------------------------------------------------------
Other - Type of Building----------------------------------- No. of Persons----------------------------------------------------
Type of Well— r- —- —- -- - ---- -- - Capacity ---------------------------------
Purpose of Well--'9Y_,__- &---/�-------------
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
Application Approved B -- - '- - -_.-— - —
` date
Application Disapproved for the following reasons:------—-----------------------—---------------------------—----------—---—--------------------
--------------------— -- - ------_--- — — —--- - - - - —--------------------------------------------------------------------
date
Permit No. "--1 - -- � ---------------- Issued--- 1� -------
- - ----- ----- ---------------------
date
BOARD OF HEALTH
TOWN OF BARNSTABLE
Certifitate ®f Compliance
THIS IS TO CERTIFY, That the Individual Well Constructed Altered ( ), or Repaired ( )
by----------Q-erv- a -------------------------------------------------------------------------
Instal er
at ` ------------------------------
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 --�~ �`�Dated
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL
SYSTEM WILL FUNCTION SATISFACTORY.
DATE-----------------—_—_ - - ------ -- Inspector----------------------------------------------— - --—--------
/ V
------ Fee
BOARD-OF.:HEALTH
`I\
TO W N' OF BA R-N'S T A B L E
[mph atcon 1for�el`C` tract o t'
i Application is he made fora permit to Construct ( �,�Akltero Repair (, an individual.Well at: .r
tC�---f e.JC �o 1. ^/� flL:� i'w,---�---- /�� r /i+U ----- --- -- --------- -
Loca fA Address Assessors Map d Parcel
f _
----------------
r .�.£.. .,u w y -�y, ,. 1; Yam# s' u P+ '� T x-rrs'Y+ ('"i•K.r CJ �ih.. '-' yw.. =.as,s
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r' Ownei �- I Address k
I S
S l � = --- ------- ------ ------d y g�.. - - -
Installer Driller A ress.
Type of Building
Dwelling _— —'== - ----------- i rp
Other - Type of Building - -- % No. of Persons-- - - --------------------------
Type of Well— _ - -- —- - - --- Capacity------------------------------------------ - - -----
Purpose of Well--L!`, �9,
Agreement:
` The undersigned agrees to install the aforedescribe I uiI well in accordance,with the pr visions;of he
Town of Barnstable'Board of Health Private Well Protection Regulation`''-Fhe uun ersi ned further agree no to r
place the well in operation until'a Certificakte[.6f Portlpance has been issued by the Board of Health.
��--ter!!
` Signed
Application Approved B �- -- ------ - — "�
dat
Application Disapproved for the following reasons:---=—---------------------—------------=---------------------------------------------
.
1
dt
Permlt'`NO. = ' � =— r..= 'Issued -= � — t — — a e —
--- ---
date
.. -....
BOARD OF HEALTH
TOWN OF BARNSTABLE
Certificate Of Comprian-ce..
THIS IS TO CERTIFY, That the Individual Well Constructed (` , Altered ( ), or Repaired j
bQ=Q"� -`'t--- CcaNn� `j -- -—---- ---- - --- - - - ----- - - - - ------
Installer
at
has been installed in accordance with the provisions of the Town of Barnstable,Board of/Health Private Well Protection
E, Regulation as described in the application for Well Construction Permit N(#-/-7p--�-�1-%Dated
THE ISSUANCE OF THIS CERTIFICATE,SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL
SYSTEM WILUTUNCTION SATISFACTORY.
DATE- - - — — — - ==---= - Inspector---------------------------- --- -------—— - - -
z
:q BOARD OF HEALTH
TOWNS OF BARNSTABLE
�eC[ �Congtruction�ermit
No. Fee
Fee ---
I
Permission is hereby granted -—- — _
to Construct(✓), Alter ( ), or Repair ( ) an Individual Well at:
If a .
L J h41
No. - L = 1 ``'--------L�_L� 1s_ -- L---`---�t---- ' - �'`� ----------------
Street
as shown on the application for a Well Construction Permit
No. --- --- --�----- -�-------------------------- Dated----------- -------------- ---------------- -----=--------------
Board of Health
DATE___
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