HomeMy WebLinkAbout0110 POINT ISABELLA ROAD - Health Poles
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No.-�- Fee - -'�----
BOARD OF HEALTH
TOWN OF BARNSTABLE
ZippYicationiforlVell Cou!5tructionperuut
Application is hereby made for a permit to Construct Alter ( ), or Repair ( )an individual Well at:
0 , f /Sab--e---l ea
-------- J LnHi�
: ------------_ --- - - -
Location — Address Assessors Map and Parcel
Owner Address
c It "n —G_ __ �°_SOX ��v ��� - �`c`- 4V6_Y_
Installer — Di=tller A dress
—
Type of Building
Dwelling---11J__14.1 ---------------------
Other - Type of Building —------ No. of Persons------------------------------
Type of Well ------- Capacity-------------- '----------------------------------------------
Purpose of Well
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 riot to
place the well in operation until a Certificate of Co liance has been issued by the Board of Health.
Signed- — --- - _l__,1_y�fO---- -
date
Application Approved By = .A
date
Application Disapproved for the following reasons:----------- --------- -------------
----------------------- — ---- -_-- _——_--- -- - — -- —--- - - ---- --— — - —_— _ —
date
Permit No. Issued----------= °'`'�--
date
BOARD OF HEALTH
TOWN OF" BARNSTABLE
(Certificate ®f (Compliance
THIS IS TO CERTIFY, That the Individual Well Constru ed.( Altered ( ), or Repaired ( )
/Y____P_�' = 6� _ �✓Y r ` -----------------------------------------------------
Insstaller
at----------f1 �[__ -°�` --- —'cS` , G " L - ' r ?'_ ---
has been installed in accordance with the provisions of the Town of B'irnstable Board of Health Private Well Protection
Regulation as.described in the application for Well Construction Permit No. Y ;&--4/ "-�- ated YY''- �
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
Veil (Con5truct ion Permit
0.
Permission is hereby granted -- L----
to Construct ( Alter ( ), or Repair ( ) an Individual Well at-
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P
No• -----1,1 _ L t�_- {`L' C� ---__- ------4G -�_ !- --- ---------------------------------- -
Street
as shown on the application for a Well Construction Permit 9
No.------- _�____ -------- - Dated--------/ '----r - -- - --
Board of Health
DATE--------------------------- - -- -- ----------------
Fee='��`'�
-- �_�---
BOARD OF HEALTH—`�
'TOWN OF BARNST'kBLE
• ���ricatiot�,�or�eYY �or��tructior��efm%t ,,�-� - .
Application is hereby madefor a permit to rC�on-s¢truct ( )Alter ( ), -or Repair (--)an individual Well at:
/ /
Locatibn — Address Assessors Map and Parcel --
Owner Address _
•R3aK k�c� 0-AY)/ _ A� q)E y� .,
N n.7e ---------- _
Installer — Driller/ Address — �-
Type of Building f f `_7 `Y
f
Dwelling
Other - Ty e of Bu
ilding
., g------------------ No. of Persons----',- �---.-�;__----------- . b
Type of Well—_-, --- ---------------- -- Capacity ' ----- ,
Purpose of•Well-! '-'G1
Agreement:
The undersign d a'grees 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}notao t`
place the well in or until a Certificate of Compliance has been issuedtby the Board of"Health.
Signed
—
c• ; date
Application Approved B
PP PP , Y- - — - date `
Application Disapp ov�d for the following reasons:------------ (/ -- ----- --
-- /----------
Nate
Permit�No. — �'! 4 -- —`�- _ - Issued —f ./� /_--�— —t -'— --—=--
I \ Oa
v BOARD OF HEZH
- TOWN OF B'ARNSTA�BLE+ ,
Certificate ®f Compliance
THIS IS TO CERTIFY, That the Individual Well Constructed ( /-) Altered ( )!or Repaired.( ')- f
'`ra 14 v��/_�Z_ -��f=�f�- `����'! �v�l�r `�� � - - ---- %----------`---
by-- — —--— — Installer +» r
at-------- --r�i— .1-%�G` — c _ �y ._ ------ s "'
has been installed infaccordance 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.
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL
SYSTEM WILL FUNCTION SATISFACTORY.
DATE---------- -�- -------------- -- —---------------- Inspector—------ —_— ---_-- — ---
LLL BOARD OF HEALT
TOWN OF BARNSTABLE
I _
e-fr Congtr act ion p fmit
No. --- -- - '_�_'_ Fee ' - -
-
' Pe ' fission Is hereby granted--------may
C
to Construct ( �Alter ( ), or Repair (" ) an Individual Well at
No. - -�/l/ -- -�rl` - ' f7 -"- '� --- a------�ls-`�_�'- 1-- — ---- ----------
treet
as show) on the apt iati,n for a Well Construction PJrmit
✓ p ;
'., —— — — , -----------
No.-----� ---�-- ---�—�-'�—�-__------------ Dated t-----------�_—_ �/ .
I
---------------
Board of Health
DATE !-__- - - - —------
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