HomeMy WebLinkAbout0010 MARTHAS WAY - Health l� fY ar4a;o �Q
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No. V- ------- Fee---- V
BOARD OF HEALTH
TOWN OF BARNSTABLE
Applicat ion Ar Vell Con5truct ion Permit
Application is hereby made for a,permit to Construct ), Alter ( ), or Repair ( )an individual Well at:
Location — Address Assessors Map and Parcel
Owner— — S�s/`t (✓ <_tl v —v ��--1�ia/<S 0"(O .
Address
6�_� r��>✓ - ,G 1-R -s6 X4 e�f ------------
Installer - Driller f Add
Type of Building
Dwelling — - ---:---------------------------------------------
Other - Type of Building----------------------------------- No. of Persons---------------------------------------------------------
Typeof Well-- ------------------------------------------------------------ Capacity------------------------------------- - ----------------------------$
Purpose of Well- --------jk�_,!fx4r,
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 By- -- ' - ---------------
'date
Application Disapproved for the following reasons:---------------------------------------------------------------_-------_---------------------------
------------------------------------------------------------------------------------------------------------__-- -— -- - -
date
PermitNo. -------------- ------- --------------------------------------------- Issued--------------------�-a-------- ----------`------------------------------------------
date
BOARD OF HEALTH
TOWN OF BARNSTABLE
Certificate Of Compliance
THIS IS T TIIFFY, T}� th ividual Well Constructed (_-4-rAl-tered ( ), or Repaired ( )
Installer
----------- r .- - -- '. ------------ ---------------------------
has been installed in accordance with the provisions of the Town of Barnstable Board of Health Private M11 Protection
Regulation as described in the application for Well Construction Permit No. -----t --Dated� U-----
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL
SYSTEM WILL FUNCTION SATISFACTORY.
DATE------------------------------------------ -- - - -------------- Inspector------------------------------------------------------------------------------
Fee-------- -
BOARD OF HEALTH
TOWN OF BARNSTABLE
ZppCication-ftlVell Con!5tructionjermit
Application is hereby made for a permit to 'Co"nstrruct ('), Alter ( ), or Repair ( )an individual Well at:
Gp7` �S lv i9- C,u �L�G�v
------------------------------------------------------------------- --------------------------------------------------------------------------------------------------
Location — Address Assessors Map and Parcel
�Uca�e -- -- - - 5
Owner Address
--- ---------------------------------------------------- ------------- ------------------ -----------------------------------------------
Installer_ Driller Addre�s
Type of Building
Dwelling- — ---------------------------------------------------
Other - Type of Building - No. of Persons---------------------------------------------------------
Type of Well-- --- -- - Capacity ------------------------------------ 1
Purpose of
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 By--- - '�., *G �112 ----- ------------------ 'C- /4--date
-�o---
Application Disapproved for the following reasons:-------------------------------------------------------------------------------------------------------------
-------------------------- ------------------------------------------------------------------------------------------------------------------------—- ---- - --------
�/�� / date
Permit No. - - —p-='-�(-Z' -- Issued-------------------_ __� _/c-', �-�- date
--
date
Y
BOARD OF HEALTH
TOWN OF BARNSTABLE
t ertif irate ®f Compliance
j THIS IS TO-CERRTIFY, Th;*theJ 4ividual Well Constructed ( .)-"Altered ( ), or Repaired ( )
by---- -------------------------------------------------- '-------------------------------------------------
Installer
at------------�._b r ...... -----------jvi _ - - - ----------------- --------- T_rv_ - -----------------------------
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. -- -I''--Dated -----
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
Yell Con5tructionVermit
' °- -�No. --- ,.�- Fee-------------------
Permission is hereby granted ------- --= - --------------_—_-------
to Construct ( ) Alter ( ), or RepaMID
) ari Individual Well at:
' ------- _r Ua s --` �-v,---�°�-----���-----------
Street
as shown on the application for a Well Construction Permit
w� - g --- �----------------------- Dated---------------- - -- ----------'--------------------------------
._ _ q ��.
------- G - ---------------------------
��,� Board of Health
DATE - -- --r --C£ - - -- -
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