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TOWN OFARBARLNSTABLE —Opp
Application-*r Melt Congtructiouperurit
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Application is hereby madefor
aVpermit to Construct (4`17 Alter ( ), o�r�[7Re )aneMddiidual------ -
------- _`= +- -"_"' -----------
Location — Address Assessors Map and Parcel
� T?—A. � t om/ 6 .' �t,--"-----------------�----- � O O� Paw �+ T
Owner Address
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Installer Driller Address
Type of Building
Dwelling-------------------------------------------------------------------
Other - Type of Building ----------- No. of
Persons--------------------------------------------------------
�TYPe of Well- -- ------ Capacity - - -
---------------------------
- -Purpose of Well--!!�l zp--_______o_ ---- _
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.
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Signed� -`�------------=------------------------------- -----�-L----- ----
date
Application Approved By— - - ----------------------- — —�--:'
— date
Application Disapproved for the following reasons:-----------------------------------------—-------------------------------
----------- -- -—----- ------ ___- ------------------------------------------------------
date
PermitNo. -w — - -- Issued--------------------------------- --- -----------------------------------------
date
Fee-� `-------- - - -
,, 1�
} BOARD OF HEALTH
TOWN OF BAR:NSTABLE
�[ l�cat�on;�otvtlt Cong.truc ML- If
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Application is hereby made fora permit to Construct ( Alter'( or Rerpair )an{i-dwidual We lI
Location� —�—/�Address --- = — — _ O P�� �AssessS" Mrap and Parcel
— — - — — -----
Owner . �a Addresev 1/�'�
of 1
Installer. Driller / - Address
Typ Building i
Other - Type of Bur�'ldar�g= e ! t No. of Persons----�z X ------- ---------
Te of Well--��--�'�- - - - -— — Capacit ---- - - --- --------------------------------------
YP Y----'- {}
Purpose of Well-,l1_!!- aliot-!
� i
Agreement: _ -
The undersigned agrees to install the aforedescribed individual well in accordance.with the provisions of The
The
,Town of Barnstable.Board of Health Private,Well P otect�brL Zegulation`� -The,i,L4ersigned further agrees not,to
,place,the well in operation until'a Certificate ampli:ance-has-been-issued-by the Board of Health.
I 'Signed
-� ��: 4� - - µ _, . � 1 --
t.. date
Application Approved By -_------- - -d -^• l lir
date
�.
Application Disapproved for the following rtasns; — ----- ----- ---- ----
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date
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Permit No --- — — - I% ssued-- - — - 1,
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BOARD OF HEALTH
TOWN OF BARNSTABLfE
Certificate ®f (Compliance
THIS IS TO CERTIFY, That the Individual Well Constructed/( 2--�, Altered ( ), or Repaired ( )
by- -- ----
-
----------
- --
at--------- s - -- -------------------------------------------------------------
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-------------------------------------------
'ter-
BOARD'OF HEALTH a
TW.N O F BARN T A 'r
S B L
Certificate Of, Compriarice
q THIS IS JO CERTIFY, That the:Indiviidual Well C/ons/t�ructe ( ,.Altered ( ) or-Repaired ( )
by --:- ----------D-A J�- -- ----� ------ ------ - --- ----- ------ - - -- ------- `------ ----- .,.
E Installer pk
— --— -- I - —
has been installed in accordance with the provisions of,theTown of Barnstable Board of Health Private Well jjProtection ;
'6 Regulation as'described in the application;for Well Construction Permit No. --- ----, -----{-Dated,. - +Q---=-------------
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL
SYSTEM WILL FUNCTION SATISFACTORY.
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DATE- - -- ----- — = ---- - -- Inspector-------------------------------------------------------------------
BOARD OF HEALTH
TOWN OF BARNSTABLE
Yell Congtruct ion Permit
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p IZ �a e
rant�d -!_" •v��'R f� �'P— —1 f Permission is hereby.g. - ---- ------- ---- -
zva to Construct-(V, Alter ( ) or-Repair;(` ) an Individual Well at:
i{ - Street.
as'shown on the application for a Well Construction Permit
. !�
- 97
No - - rim - - Dated=---- -- ------- ---------------- ---- ------------ - --------
tr
,•= ,,, x� Board of Health
` DATE'S` ---
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3 Department of Environmental Management/Division of Water Resou
,. T WELL COMPLETION REPORT
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WELL LOCATIO.ftl: n r,,, I{ GEOGRAPHIC DESCRIPTION
Address /<►K / t
G O pG�4• t 00 Q N S,E. W of
City/Town I� liNNrS
(feet) (circle)
Well owner J � 2A, Ilta/( (road). .
Address �' Ok `p N S E W of
14
,,.� (nil.in tenths! (circle).
Board of Health permit obtained: yes ❑ no.❑ imersecr.'w/ (road)
WELC USE WELL DATA
Domestic❑ Public❑ Industrial ❑ Total well depth ft.'
Monitoring,❑ Other fir'�o`' Depth to bedrock`
Method drilled
(A 6P WaIer-bearing rocklitnconsolidated material:
Description
Date drilled 6 Water bearing zones:
CASING I) From To
TypeG� YD �L
2) From To
Lertgth, it. DiaO.D.) ; in: 31 From To
Length into bedrock ft.
Grayel pack well: dia.
Protective well seal:
Screen: a ld.
Grout.❑ Other Slo ,$ �J length from—,to—
STATIC WATER LEVEL(all wells) �0
Static water level below land surface ft. Date
WELL TE$T(production wells)
Drawdown�.—ft. eftor pumping Jtr. min.at/11 r gpm
�u�M� fZ4
p How measuredN L Recovery, it: aI ter_hr. min.
. c
LOG of FORMATIONS COMMENTS.
Materials Front To
D
Driller
Firm' :dA S /-
'` Address
(vJc.'v a O Clty jownth.)a,(�
Supervising`Driller RegA
Si nature or supervisin ke isteled well driller
Please Print firmly - -
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