HomeMy WebLinkAbout58, 66 JOAQUIM ROAD - Health 5 8'&_66 Joanquin Rd.;Hyarinis tc:r F i I v Y
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No. Fee-------� � =�y �
------------
BOARD OF HEALTH
TOWN OF BARNSTABLE
Applicat ion for lVell ConQructionHermit
A,ppplication is here y ade for 'permit,to Construct (�; Alter ( ), Mair ( )an individual Well at:
y /C �oogy«�
o Location — Address Assessors Map and Parcel
1/
�TTT�n/ Owner Address —
_���
Installer — Driller Addre _
—_
Type of Building
Dwelling -----�--— ---
Other - Type of Building No. of Persons----------------------
Type of Well °4Se� J� C Capacity ,�S-G ��---
Purpose of Well �` `.�' 7 '
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 Cert'fi ate of e has been issued by the Board of Health.
Signed
to
Application Approved By � � ---
date
Application Disapproved for the following reasons: ----
' v date-- ^
Permit No. �'= -=y — Issued
date
BOARD OF HEALTH
TOWN OF BARNSTABLE
Certificate (Of Compliance
THIS IS TO CERTIFY, That the Individual Well Constructed), Altered ( ), or Repaired ( )
by—} Installer --— — ——— -- — —
at ----------
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. - 1 y Datedv�-
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL
SYSTEM WILL FUNCTION SATISFACTORY.
DATE Inspector--- --- —____
_��
No. Fee------�---------
BOARD OF HEALTH
TOWN OF BARNSTABLE
0(pplicat ion for IV ell Con!gtruct ion Permit
ppl'cation is hefe y ade for . permit to Construct ( Alter (, ) or Re air ( )an individual Well at:
�oT S/�/p_G_S/ 3- — 6 3 _
Location — Address T' T Assessors Map and Parcel
Owner Address
Installer — Driller Addresi —
)Type of Building
Dwelling
Other -.Type of Building No. of Persons-------------------------_____
Type of Well Capacity
Purpose of Well le,!L
Agreement: ;
The undersigned agrees to install the afor'edescribed 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 Cer 'fi at of p ' e has been issued by the Board of Health.
L1 o2..-e 2
Signed ---
!:41
. ate
Application Approved Bye ---- ��
date
Application Disapproved for theYollowing reasons:
date
I
Permit No. "�� � l� — Issued �" —
date
BOARD OF HEALTH
TOWN OF BARNSTABLE
Certificate (Of Compliance
THIS IS TO CERTIFY, That the Individual Well Constructed), Altered ( ), or Repaired ( )
by— — -- Installerat
--— — ---— — — —
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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.�DKQDK J-y--Dated tOr,
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL
SYSTEM WILL FUNCTION SATISFACTORY.
DATE-- Anspector-- -- --- ----
BOARD OF HEALTH
TOWN OF BARNSTABLE . .
Ivell Contruct ion Permit
�I S
No. —
Fee----
Permission is hereby granted — -------
to Construct (4.), Alter ( ), or Repair ( an Individual Well at:
No. Lcy Iy
Street ----------
as shown on the application for a Well Construction Permit
No.- Dated -- ( ---------------"--
ak,
(_/ Board of Health
DATE
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ASSESSORS MAF
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152.275, .