HomeMy WebLinkAbout0190 VINEYARD ROAD - Health ay-rj 620a
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No.o____ q----- BOARD OF HEALTH Fee---- ----------------
TOWN OF BARNSTABLE
Application-*r Melt Con0ructionpermit
Application is hereby made for a permit to Construct ( ), Alter ( ), or Repair (man individual Well at:
`Z.
Location — Address ^ Assessors Map and Parcel
orb
Owner Address
-__-
Installer — Driller Address
Type of Building
DwellingAV--s 1------------------------------------------------
Other - Type of Building -------- No. of Persons--------------------------___—__—_______
Type of Well y !�-� _—------------------- -- -
YP - - 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 not to
place the well in operation until a Certificate .of Compliance has been issued by the Board of Health.
Signed --�------------ ----- �------ ��------- i
date
MV41-
Application Approved By mil_ — ----
date
Application Disapproved for the following reasons --------=----_____—-----_—__________—__�_—_____
-- ----- -- date------
Permit No.
--------- Issued
dat----- - ----
BOARD OF HEALTH
TOWN OF BARNSTABLE
(fertificate ®f Compliance
THIS IS TO CERTIFY, That the Individual Well Constructed ( ), Altered ( ), or Repaired ( -1
----------------------------------
Installer
V
at /qO */9 Aj G07s'"
has been installed in accordance with the provisions of the Town of Barnstable B of a lth rivate Well Protection
Regulation as described in the application for Well Construction Permit N - -- -_ __Dated-----THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL
SYSTEM WILL FUNCTION SATISFACTORY.
DATE--- Inspector------------------_ _ ___
No.A----- Fee---- ----------------
BOARD, OF HEALTH
TOWN OF BARN TABL , •
Citation for eIC Congtrustion ertnit
Application is. hereby'*
ereb 'made'for a'permit,to -enstruct ); Alter ( ),'or,Repair ( an in ividual Well at:
y rJ. 9 v
Location ;Address Assessors Map and"Parcel „
01
/" _ Owner — ---— —— U Ux 4J O dress
—N --
Installer - Driller Address .;
Type of.Building. !
Dwelling- /ou c_-'
Other I- Type.of Building; -- ------- --'- No. of Persons--— ------- - ---. —
Type of Well-y �J L `_ - _ Capacity -- -- ---- - - -- —
Purpose of Well&,'4rSTic �! -----
Agreement:
The undersigned agrees to uistall the aforedescribed individual.w�1 to accordance with the provisions of The
Town of,Barnstable Board of,Health Private Well, Protection'Regulation 4undekitned further.agrees not to:
place the'well in oper"er-ui�tii�-Certificate--of- mphante-has btert-i-s-sire&Gy ffie Board;of-Health:--
p date
Application'Approved By - =-® - -- - -
date,
Application Disapproved for,the`following reasons: ---=— _____: _—
date,
Permit No — -- Issued--- -
9 -__- - _
t date
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. BOARD OF HEALTH
TOWN ' OF BARNSTABLE
ertif irate f Compliance
THIS IS TO CERTIFY That the Individual Well Constructed ( ), Altered ( ), or Repaired ( �
///� d ff _
I `10 (�rK o/cl
Installer
at ---- — C oca r'� — -- - --
has been installed in accordance with:the provisions of the Town of Barnstable B of Health rivate Well Protection
Regulation as, described in the-application
g pp cation for Well Construction Permit N - - -:Dated- --_- ___
THE ISSUANCE OF THIS CERTIFICATE:SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL .
SYSTEM WILL FUNCTION SATISFACTORY.
DATE Inspector=-
�' -- - - — —Y
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BOARD OF HEALTH
I•
TOWN` OF BARNSTABLE ` :
�eCl �on�truction��ertrtt � _
No. ----- - Fee- -
Permission is hereby granted
A SCuNwI-/l - --_
to Construct (�; Alter ( ), or Repair (, ) an Individual Well.at:
—— Street — — —— — —
as shown on the application for a Well Construction Permit
N
Date'
Arl,
Board o ealth
DATE CH
Y.
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