HomeMy WebLinkAbout0073 WILD GOOSE WAY - Health (2) d GCCG-0- - 0
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No. - --/47 Fee—Z
BOARD OF HEALTH
TOWN OF BARNSTABLE
ZIpp[itation-*rVell Cootructionpermit
Application is hereby made for a permit.to Copstruct ( vj, Alter ( ), or Repair ( )an individual Well at:
Locatiof Address Assessors Map and Parcel
----- ---- z/
Q Address
RV �f e
—/—---—--------------------------------------------------—--- 1-c-NC7f�JC�C _w __AD_f!a�
"Installer — Driller Address f
Type of Building
Dwelling ------— -- ---— — ---------
Other - Type of Building----------___—---------------_ No. of Persons------—-------------------- -
Type of Well—'`r/. �C-------
Purpose of Well_11 d_` -----------------------------------
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 Ce tificate of Compliance has been issued by the Board of Health.
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Signed - ------------------------____ __—_—____ _ ��_
Application Approved =�-���----------------(----- ---___ ��-- ��--_��
date
Application Disapproved for the following reasons:-------—------------------------__--____________________________--______
date
Permit No. '! "/ _ - — -- Issued—-- - ---—- -—j-
date —
BOARD OF HEALTH
TOWN OF BARNSTABLE
Certificate ®f Compliance
THIS IS TO CEIUIFY, That the Individual Well Constructed Altered ( ), or Repairedby
( )
- ------------------------
---------------------- -------
J) Installer
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 4--,-G7,4'1_-9Dated
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS'A GUARANTEE THAT THE WELL
SYSTEM WILL FUNCTION SATISFACTORY.
DATE —---------------- -----------—-- -- _-- -—-- Inspector-- — - - - — — — -- -- ——__-
a �
Z5, 41D
No.- ------ --�--- ' _ Fee---------------------
BOARD OF HEALTH
TOWN OF BARNSTABLE
21ppritation fforlVerr Congtructionpermit
Application is hereby made for a permit to Co struct ( , Alter ( ), or Repair ( )an individual Well at:
Locati9n — Address Assessors Map and Parcel
G`/S,�l �zt �(/. r -co �_ �� /s ,F J� C�, �,,�, /� ' ,, a
-� - ---- - ----------------- -- - -- - --- - - -
Owner �A`ddress
fd
-NNP- / /______-__-
Installer — Driller Address
Type of Building
Dwelling-----—------------------------------------— - -
Other - Type of Building------------------------------ No. of Persons---------------------------------------------------------
Type (r
of Well-��—= v -- --------------------- - --------- Capacity - - -------------------------------
- p y- - - - - - - -
Purpose of Well �/✓!G�.ro1_ -__----_----------
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 Cer'tificat of Compliance has been issued by the Board of Health.
a /
Signed-- -----------
Application -
--- -- ------------------ ------------------- dat
Approved - - ------------------ -- ------- ��------
- -- � �r date
Application Disapproved for the following reasons:---------------------------------------------------------------------------------
--------------------------------------------------------------------------—- - -=-- - -- - - — - - - —--- —__- — --
v date
Permit No.-rr---~ E�--/! -r- ----------- Issued------------- - —- - - ------------------- date /
BOARD OF HEALTH
TOWN OF BARNSTABLE
(Certificate Of Compriante
THIS IS TO CER-TIFY, That the Individual Well Constructed ("), Altered ( ), or Repaired ( )
0'A 3CO �
--- ------------------------------
,I/nstaller
F c� C� P a J PJ(J/ /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 . --- -,724 �- ---e
Dated-��---�----�'�---��---- 7' z74'
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
Very Con5tructionvermit
No. ---------------------- ! Fee "----f�--
Permission Is hereby granted ------------------------------------------------------------------------------------
to Construct (--); Alter ( ), or Repair ( ) an Individual Well at:
/1-
No. - = -v' ---- y----------—------ —
-----------------
Street
as shown on the application for a Well Construction Permit
No.--- —- — — ----------------- Dated----------
/ Board of-Health
DATE------- �� --- ---------------------------�`-�