HomeMy WebLinkAbout0051 MARTHAS WAY - Health (2) 0
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No.---
BOARD OF HEALTH
TOWN OF BARNSTABLE
A.pprication,forIftl Constructionpermit
Application is hereby made or a.permi _ nstruct (x, Alter ( ), or Repair ( )an individual Well at:
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Location — Address Assessors Map and Parcel
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Owner Address
7_6 _ - d�? -ems-
nstaller — n er � Address
Type of Building
Dwelling--- �d!�1 -------------------- r
Other - Type of Building-------------=---------=--- No. of Persons—
Type of Well-----�#'� Capacity &//)rA�
Purpose of Well--- � =� '-�' ---- -
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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 rCertifica a of Compliance has been issued by the Board of Health.
Signed- -- -- ----------------------1-�� -— --- -7 '-��-�4=3—-
f�j date
Application Approved By --- � -- - _ '
-- - - -- ---------
date
Application Disapproved for the following reasons:---------------------_____--_______ —----_____
�L date
Permit No.--�'Y__� — -" --- Issued------------ �'-- " _raj----
- -------------
date
BOARD OF HEALTH
TOWN OF BARNSTABLE
Certiftratr Of COMPhance
THIS IS TO CERTIFY, That the Individual Well Constructed ( ), Altered ( ), or Repaired ( )
-- ---------------------------------------- -- —-- - —
Installer
at---'-�---�----��` ,�----- ra` r�----- �- - --
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.*�=-�_'_-5�ated-;F—fn--Z f`
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL
SYSTEM WILL FUNCTION SATISFACTORY.
DATE------------------------------------------------------------------------------------- Inspector--------------------------------------------------------------------
Fee---'��-- ---
B4OARD OF HEALTH
TOWN OF BARNSTABLE
Application-for Velr Congtruct ion Permit
Application is hereby made for a permit to Construct ( , Alter ( ), or Repair ( )an individual Well at:
r �l ocation — Address Assessors Map and arcel
Owner Address
_— —!t_s*k rrr�i ` r rT '� ` — ----------/��jY�s !+_�
nstalle, nl er — Address 7
Type of Building S 3
Dwelling ' -
Other - Type of Building- - ----------- No. of Persons-----
Type of Well----- -:o - Capacityr� � `, ` '��' 6 �C
Purpose of Well-----,---e-ti--------�v� �� f•+'`
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 Certifica e of Compliance has been issued by the Board of Health.
\Signed j-- -- - L t - '_------ -
date
Application Approved By - � --- --- 7--:!-
date
Application Disapproved for the following reasons:--------------------------------__________________----------_--------------------------__---_--__-_-__---_
-- - ----- - - - - - - - -- ------ ------------- ----------------------------- -- -
date
- -' -- ' '= _ -----------------
Permit No.-- ��-----. --"------ - Issued---------------=
date
I BOARD OF HEALTH
TOWN OF BARNSTABLE
certificate Of.Compliance
THIS IS TO CERTIFY, That the Individual.Well.Constructed ( ), Altered ( ), or Repaired ( )
------------------------------------------------------ '
Installer ------------------------------------------
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.& �--V-"- ---
g PP � �-gated
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 ¢
Ivell Congtruct ion permit
Fee-------------------�
Permission is hereby granted--- -----»� ->.' !; --------------------------------------------------------------------
to Construct ( ); Alter ( ), or Repair ).an Individu�al Wr--elI t:
NO. - -- =- !!� - Scree ---------�-- -4-5 � ----- ------------------
as shown on the application for a Well Construction Permit
No.-------- ------ " "_---44 -----------------�'�----------------- Dated----------------- r - �------------------
Board of Health t
DATE------- = � ------------------------
Department of Environmental Management/Division of Water Resources
a
WELL COMPLETION REPORT
WELL LOCATION `; GEOGRAPHIC DESCRIPTION
Address
N S E W of
peed (circle)
City/Town ey-44,zeie 64 6 G6"r
Well owner .*& 04.i—�� ��sr P froadl
Address i/� y<+�F fin' / N S E W of
��,�a 7— CL Q (n i.in tenths! (clydel
Board of Health permit obtained: yes Ell' no Ellnrersect. w/ (road!
WELL USE WELL DATA
Domestic Public❑ Industrial ❑ Total well depth—=_�ft.
Monitoring❑ Other Depth to bedrock ft.
Water-bearing rock/unconsolidated material:
Method drilled�da .44r6E02
Date drilled
Description
�f.�. ��$
Water-bearing zones:
CASING 1) From To
Type 4_4 44) >D
2) From To
Length—/-4w—ft. Dia(.I.D.) —in. 3) From To
Length into bedrock ft.
Protective well seal: Gravel pack well: dia.
,
Screen: dia.
Grout-El . Other Slot r`—,ea—length i from_za&to,4qg_
STATIC WATER LEVEL(all wells)
Static water level below land surface — ,f.t. Date Z. 9 R
WELL TEST(production wells)
Drawdown a It, after pumping 2 hr. _tnin.at gprn
How measurecPX4,w_-_AoAd_Recovery N 4,:2 min.
o
LOG of FORMATIONS COMMENTS
Materials Fionr- To
DrillerESrrrirr�71
Firm L.L,,1,,,.r»,4 �1�//. fP It-(1nr
Address • Aa — .
City/Town 1t!E-FgZ:5 d1,47.
Supervising Driller Reg.tt
i na u ipervisi tered well'driller
?less print firmly BOARD .OF HE:ALTH...'COPY.�