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HomeMy WebLinkAbout0135 CHIPPINGSTONE ROAD - Health 135 Chippingstone Road, Atarstons Mills A= 028 - 027 1 LOCATION SEWAGE. PERMIT NO. VILLAGE � 1/15 � '6-QINSTA LLER'S , NAME A ADDRESS _ \J w ` I UILDER OR SOWN ER tv !Torz kk A-k FDA T E P ERMIT ISSN E D DATE COMPLIANCE ISSUED ��/,r 4• ..,� D 1 • `�� � •x ���� �' s, � ��. .. .��� ��P�,,;�� spa-�� Department of Environmental Management/Division of Water.Resources 6 WELL COMPLETION REPORT ! WELL LOCATION k GEOGRAPHIC DESCRIPTION Address I .Sr C�`�fa10C FOB •,0 IN 0E W of (feet) (circle) CitylTown .lKwSitos %11 RA OZ6y S (o- c � 1 1N811 owner ��� ff k (road) Address' �'Z hsba IV&S-�.n `6 N S E 6 of (mi.in tenths)_ (circle) �,s ,Js tM `t►s '� o26yTS ---T Board of Health permit obtained: yes V no❑ Intersect. w/!ti•r�✓'�_ (road) WELL USE WELL DATA Domestic Public❑. Industrial ❑ Total well depth 5 -ft. Monitoring❑ Other Depth to bedrock ft. Water-bearing rock/ nconsolidated mated I: Method drilled � Description!' Date drilled )QIg Water-bearing.zones: CASING .. 1) From To 'Type b- C 2) From To Length _ft: Dia(I.D.)Jf_,in. 3) From To Length into bedrock ft. Gravel pack well: dia. Protective well seal: dia. Screen: c ' Grout ❑ Other Slot# w 'length from to STATIC WATER LEVEL (all wells) [f Static water level below land surface `� ft. Date—!� WELL TEST(production wells) �Dr�wdown �Tin. ft. after pumping hr atgpm How measured Recovery '' r hr. min. LOG of:FORMATIONS COMMENTS 0 Material's From To f Driller r-' � �cNt, Firm C LA t t i- 001Y.Se Address i d d I' City/Town Supervising Driller.Reg.# t e� �'h Signat re of supervising registered well driller Please print firmly BOARD OF HEALTH COPY THE TOWN OF BARNSTABLE yDi Taw ibvP�f� OFFICE OF i Dsaa7TSDr, i BOARD OF HEALTH i639. 367 MAIN STREET �a MIRY w HYANNIS, MASS.02601 August 26, 1997 John Kovach 135 Chippingstone Road Marstons Mills, MA 02648 Dear Mr. Kovach: You are granted a variance to construct an addition to your home, at 135 Chippingstone Road, Marstons Mills, only five feet nine inches (5'9") away from your existing septic tank. Title 5, the State Environmental Code, requires a ten feet separation distance. However, the local approving authority may vary this provision up to five feet. Please ensure that the septic tank remains easily accessible for future cleaning and maintenance. Sincerely yours, /0,4<V tA-0-- - Susan G. Rask, R.S. Chairman Board of Health Town of Barnstable SGR/bcs kovach _._ _ ............... 1 _ _ lk +o THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ...................... ....................0 F.......................................................................................... Appliration for Diipuaal Workii Tnnitxnrtinn trntit Application is hereby made for a Permit to Construct (v) or Repair ( ) an Individual Sewage Disposal System at: Location.Addr ss or Lot No. .......6.........t - -& ... .... 21.....--s�.�v�°�c� �i-----.. .....�u,u Own Address ............•-----•-•-•-••---... Instal er- Address d Type of Building - Size Lot... ;Z.b._ _.Sq. feet U Dwelling—No. of Bedrooms._........k-------------- -- _Expansion Attic (1J o) Garbage Grinder (he) aOther—Type of Building ............................ No. of persons----..-_____-___--_--_______ Showers (I — Cafeteria ( ) a' Other fixtures ................................. . W Design Flow...............r ,!r......_......_..gallons per person per day. Total daily flow.........klc......................gallons. WSeptic Tank—Liquid capacity/jOCO.gallons Length................ Width................ Diameter---------------- Depth................ Disposal Trench—No..................... Width-, ....... Total Length............ ...... Total leaching area....................sq. ft. Seepage Pit No------)------------- Diameter..�.C�.` -!_-.._. Depth below inlet---G.'� .__.... Total leaching area..................sq. ft. Z Other Distribution box (r ) Dosing tPik ( )Ad �" Percolation Test R4"tes formed by..... 1.k-�_ ...................................... Date.__ ,<i3�� � ......... Test Pit No. per inch Depth of Test Pit.................... Depth to ground water........................ Lz, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth o ground water........................ ----� ---•-t•-•- -y---.-- -•-- -- ........ + O e 1 s V _j..... Des r ti f Soil ,8�l�. !� - -- ---------- --- !� w 7------ ..-----a, ���&- L. U Nature of Repairs or Alterations—Answer when applica e................................................................................................ �. -•--------------------------•-------------------------------------------•-----•--------------•-•---•--------•---------------------------------------------------------------------------------.......... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in op tion until a Certificate of Compliance has been issued by the board of health. Signed - (�, ��� ----------------••--....t� A ication Approved By--•••-•--- �L ... .--•-•• .•. -•••-••......................•.------ -•--•-.p _ �.Dal-e-• .g'I V _ Date Application Disapproved for the following reasons-----------------------••------------•---------•-------....----•-----------------•--------------------•••..I—- .................................................................................................................................................................................................... Date PermitNo......................................................... Issued........................................................ Date ��....��.r. Fizs..... ............� THE COMMONWEALTH OF MASSACHUSETTS ' BOARD OF HEALTH A p iratinn for Disposal Works Tonstrnrtiun ramit k § Application is hereby made for a Permit to Construct (v) or Repair ( ) an Individual Sewage Disposal 4 I System at: ......................or 4 4. �. j k�gc.. . Location-Adress or Lot No. ................ �► ..........2.. .......W l:P_YC.Y..• -. •-1�Y ----••......•---•INK,3 la u... W -7 � Owne Jr'O ��� Address a ......................... ... ; .. .... ...------•-----....--•-----••-•---...........---•-•--------..._......................•..... Insta ler Address Type of Building Size Lot..#J.t.,...:Z$4...Sq. feet Dwelling—No. of Bedrooms........:.::.................•.__.._..Expansion Attic 9 Q) Garbage Grinder Ga _........_ No. of persons......................... Showers y Cafeteria � Other—Type e of Building p ) a Other•fixtures .........................................................• ••--••......-•------••-•-- ----•--••--•••------•-••...•-••-...•--•----------------•-•---••---•- W Design Flow............... ,pr.s• gallons per person per day. Total daily flow.__..... _. gal g u3 �a loos. WSeptic Tank—Liquid capacitil000..gallons Length................ Width................ Diameter---------- Depth................ x Disposal Trench—No..................... Width...__. ............ Total Length....... Total leaching area....................sq. ft. Seepage Pit No...... ............. Diameter.-IQ,. Depth below inlet................... Total leaching area..................sq. ft. Z Other Distribution box ( Dosing tank ) `-' Percolation Test R ults .- Performed by..... Date"? y �l ,l 14 Test Pit No. 4� ! hutes per inch Depth of Test Pit.................... Depth to ground water............:-__---_-__. ��=---- P P _ P fT4 Test Pit No. 2................minuteg�per inch Depth of Test Pit.................... Depth to ground water........................ Ix •------•••--.... _....••. •........ -•--- ---------- A.. .---- �n Desc pt f Soil-•- •.. 2 "`,...... -S-•-•••�......l -- x o - ........................... .. -. �s, cs.4,t ----------------------------------------------------- U Nature of Repairs or Alterations—Answer when applica le6 .�..:.................................... ............................--- ---------- --------------------------------------------------------------------------------- Agreement: The undersigned:agrees to install the aforedescribed'Individual Sewage Disposal System in accordance with the provisions of TITI1 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. Signed{ ^ ••-•----••--• •0.• � 0 jay CT�! Application Approved By.......... d ------------- r Date Application Disapproved for the following reasons:---•---•-----------•-----------•-----------------------•----------------------------••-•--:-••-••-••-........._ .................•--•--------•--------------•------------•--•-•-------•-•....-••••-- 3 Date Permit No. =------------------------- Issued -- - Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF EALTH �".... (..........OF..............0......... /' Z.! ................................... �rdifiratr of Tumplianrr T O�C� IFY, That,the I ivi al w e Disposal System constructed .(. ) or Repaired ( ) t--••.'' by . d ....................... in faller J has been installed"m accorda�ith the provisions at........ta of TIT ate Sanitary Code as described in the a lication for Disposal-Works Construction Permit No._,_, o.- dated - ....................................... THE,ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A 4GARANTEE.,THAT THE SYSTEA+1WILL FUNCTION AT SFACTORY. DATE..............•......._..•-•-�02. 8---------...-.-------••-•-••----... Inspector.-•----='---------------------------- ............................. THE COMMONWEALTH OF MASSACHUSETTS BOARD Q HEALTH ...............OF.......... I...... .�. --.... ........ ......... FEE.....-•----•--.......... Maps W , (9n wtion Vrrmit Permis'siV-4-- ereby granted ----•-•--- z----•-•------------------------------ to Qgsquct ( ) Z epair ( ) an Individual S yge Disposal f, at . f; _'C7 X-eet C_ ;I A/S---- as shown on the application.for Disposal Works Construction- Permit No..................... Dated.......................................... ' t // m Board of Health DATE------------------------------•-•-- h �/ FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS r� 4 . 1 fi. 77777 'At s- PM1 v,0q TE� V D 14AD ?x a 99•� wEAe PROP VEWAW sap n G S�/S"iI M gi WEFT^ 10=5. MA�rfZ /r0!/N� '73-o12, DA l�fl MAC(!,"-7 /xFa r}' 7 �I r f atA NEI R nnPr � iT 2 �Mfb4 .4 �s sS� ZcSUE P—F a x� �*�y t rr ^.��. ^—•--'�._ ;tom ' 43 .moo s. 4- •s' rlN Q 7 ' rvA 4•9L rr F►(/�' $ �� FQOUT �<✓1 �SPc � '. LG`�T G e ,f' {j"F�/4llkftf ' s Z 1Sx �I�E a Ll /\L n{/ S. •j 1 � .r�x�. )! •w - �off � i 4 �_._._.�._, .., � 0 4 c ASSutit�D PG��EcTK�%1 ' ' E , + }�.f I, Z 1 ram. �r q - AWT I Q � � x 9 uKtAEQ A2T 7 c�{Pc#T C `.� QD > ..+ F�f 'y�.�.�(]}�� Ki l��riy_p�;'. i 5•. fY OF M,4 Wx7 .F�41 "" �'l.H- � �OHN ,� v rn w " _ Si LT -r`( C LA-./ O B al QE k' F r, d �r % 4 r �� 'f�riF t� ti,14� .. S ,�._ ., rk•. �L.,� t s N 9'3, �� ru`l�tA�l ltnprrQ M[svEiJ Fob to rEET r, ' Y N 2S?4�p ' i ucrr E l�rD 1 11C t I f N6{>4CtL ALL I)ICECi-1CWS, ftW,W Q/8T6 �04 Gc ,! IT S Ec-not.l 2•••1-7,'71TL t 4A'G sUR`� S 7 A7'>= r:l n_fl •.a ;.2 .. t. ill, lipsS Y w xt W i` r a : 1O L . (VACAWIT) NAC-A KIT) k. :•asp; . LEGEND EXISTING SPOT ELEVATION' " CxO ` {.���thofM,�s CERTIFIED PLOT � PLAN 7 EXISTING CONTOUR ---.0 ..._� �� oy L.a7 s� c���P�in%Gsrot✓ ,: � r FINISHED SPOT ELEVATION �yq� � l�ST0/vl /'�1i�-L.S FINISHED CONTOUR ,---�.. 0.�;,..�.. � ►A.a �, RSE,,{ APPROVED'$ BOARD OF, HEALTH No aQ951wp S/ONA�� i y DATE AGENT SCALE j / 90 DATE, 7 /z 3/k2- TDRE06E E1VG/N 'E'R9hl� N� C . ITgo � E a w — -----* !• CERTIFY THAT THE FROPOSEA"; EGlSTEIa RE 1ST .4 p BUILDING SHOWN ON THIS PLAN f: MIL .AND ' ` �h , ZONFORMS TO THE ZONING LA�r., OP ,,SARNSTA® E SS. �uc�PT f ,712 MAIN STREET � � '. CAI• ���'` •/�'E, �< A �r.�stCQ k y ,,.NlAS:3 .. SNEE$, i?�';.z�: DATE R LAND SURV /Y07'E /F E'/7-HeT THE SFPT/C TANK OR j e• - 20 FT- M//V. 1Er4CN//YG P/T ARE MORE THA:'ti/ /2"5EL0/N /O PT .1 AGE', rQ 24 "O/A M E TER CONCH -- CO NE.P SHALL BE BROUGHT To GRA oE.�•-�,ti EXTRA ----------- pi Pz xlE.4VY CAST /RO/Y COV-EW SH14L.L- 43E 41SE.0 MIN. P/TGN /F//V DR/V—=WA Y GCL. i o2,o COVERS �9"�,/,r,4, CO/VCRC7 _ 2 . Mini. COVER , CLEAN .SANG Ligulo LEYEL _ f4' 2 LAYER 4-; .o"CAST GAL, o •�0 � • • • • . • • • ,ems• � QF �8 - �e d' MIN.O/r4N p/ST, WASHED 57bNE SEPT/C TA/VEC ' • b • • • . . . • • , BOX o + • • • 8 • • o • • � • . ?r, • •EFFECT/VE • • • • •314+- V2.. • ° " • • DEPTH • • • ► • o r WASJ�iEO STONE •• O 14L- �, ; •� • • • • • • • • ► D _ ► a. . • • o • o • • • • p,•p PRECAST SEEPAGE � X �L•S `+ 70 �lC s �. • • • • • • • • I a o J/7 OR EQU/V- /lVViPRT 4ff4 EVAT/ON s - 85 -7 3 �/D A /NYERT.AT QU/LD/NG 98.5 Fir �_ 1JVLET SEPT/C Ti4NK 98•3 FT- '(I Cf ( r i c e, I'� ! FT. G/.4M. Ce SEE Ts1BULAT/O/V, Ou74RT'SEPT/C TANK `�8•L Fr Q1 9 GROvVV w,47,elW TA•9LE i /NLET D/STR/BUVON BOX' FT SECTION OF 007LETD/3TR/BUT/ON BOX 91 •7 FT SEWAG46 OISPO�SA L SYS7'4&M hVZ,=r LEACHINC f'/T 9—SFr. 7A- 8Z1LAT/D/V LEACfO/NG f?/T D/MEN.S/ON A 3•5 FT. DES/G/V CR/TER/A SCALE : %4" _ / -O p/.+LE)VS/ON 8 FT. D/MENS/ON G ¢ FT. NIJ/NBER OF BEDROOMS 3 Gj1R8A4GE0/5PO.SA4 UN/r_L/o SOIL. LOG TOTAL EJT/MATED FLOry 33 o GAL.IDAY SO/L TEST / SOU TEST 2 r NUMBER OF 40ACHIMG P/T,S_-/ f^F[e�K 99'4 ��L, 99 Z OA7 OF SO/L TES' �:' 3 y S/DE LEACH/NG-PER P/T /,LE- S;t /`< •�ti-X D _ 3 2- U - Z ' RESULTS /'V/T/1/ESSED BY BOTTOM LE�9CN/NG PER P/T S4• LDA"� FT � Lo..�r� & PtRCOLAT/ON DATE / LE'S s l+•J!/Vy/JNCK 5ueso/L - y-t.r�a,i-.• AERCOLA7'/ON R.�A7'E�2 TOTAL LEAG'N/NG AREA SQ• FT. 2P RESERVELEACHINGAREA �� SQ. FT. OF M�`fS ✓� 5/L-rY c..%AV i i ► w" iq�. toy 9� - x CZ A 1 t Z. _ n,. • No. 10951 O l ' F^ 74�a ✓ 'F: _',__ L ELOREDGEE/NG/MEEI�/lVG cc,/NG. f��`�c4��� IqN�ST2�yOQ` 'L Fs7 E� , F7 i 7J2 AlAlN ST. , HYA.VNiS. MASS; I NO G RO UND LYr4 7-&R -.NCO CJ/V TL�i2 E0 E- DRTE `v�� Q GROUND Y�/ATE.P AT FLEv - 0a NO: l SHEET=OF U I - 9 ASSESSORS MAP NO: P� No. A '�-/�- `=9 PARCEL NO: Fee--- BOARDOF HEALTH TOWN OF BARNSTABLE 0[ppiiration-*rVe[r Con0rurtion3permit Application is hereby made for a permit to Construct ( ), Alter ( ), or Repair ( 6,'an individual Well at: .p Location — Address Assessors Map and Parcel 13 S Owner I Address ----------------------------— —— /n p--A--y----- foes__ t ~-`�—` `—��G Y ------ Installer — Driller Address Type of Building Dwelling— ®u-�-e ------------------------------------------- Other - Type of Building------------------------ No. of Persons-------------------------_____ Type of Well—4/� J, —--- --—------- 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 ------- --- --� r��Sg---- date Application Approved B = —`�v-- ------ f 'r f ` `°`!_ - date Application Disapproved for the following reasons:----------=-----------_—_--_______— --- ------------ - --- ----------------------------------------------------- date Permit No. / _ -------- Issued—�--�-----------/�----- J0--�date --- BOARD OF HEALTH TOWN OF BARN4sTEAJ%69 C ertif irate Of CompfftfO: THIS IS TO CERTIFY, That the Individual Well Constructed ( ), Altered ( ), or Repaired n�eve--1------------------------------------------- Installer / 3 S. t d°P, s ro e ,� c AA r has been installed in actor ante with the provisions of the Town of Barnstable Board of Health Private Well Protection Regulation as described in the application for Well Construction Permit 1�P`4!--, —�'—9Dated THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORY. DATE - Inspector------________— - 4,of7 '0 IV IF 1 �. .�_9 0 8 1-�--ar-w_- { No.- - ------ -- Fee--- -- ----- BOARD OF HEALTH TOWN OF BARNSTABLE ZlppCication_*r),VeCY Contructionpermit I Application is hereby made for a permit to Construct ( ), _Alter ( ), or Repair ( ✓Ya individual Well at: Location Address Assessors Map and Parcel :_--_--- -(�—— Owner Address -----Di_Jk-&S a_NIVr - ----------------------- Installer — Driller Address Type of Building Dwelling---� e------------------------------------------- Other - Type of Building-----------_---------__--------- No. of Persons --------------------- ____------ Type of Well ;� 1=2 - Ga a`ci Z i Purpose of.Well QU cs t,c_ � f ,��- —---- --- — i IV Agreement: ` The undersigned agr f es to install the aforedescribed individual well in accordance with the provisions of The Town of BarnstablSS (jaol' Health Private Well Protection Regulation - The undersigned further agrees not to 3 _place_the-well-in-vperatiow anti a-Certificate .of Compliance was bin-issued-by-the-Boar-&of_Health f date f Application Approved B date Application Disapproved for the following reasons: '�� -- -- ---- �- date Permit No. � '" _ Issued - date ----- - 4a!�!a!elgy�fi!<?�filmli4�.¢nr>!ofi8&lul3S(l7al odl6r�e9�SsPLla4a!►lMilZAliISS •►itdTaiPilf:Veli@Y!¢5!lil�ia7dtiie'¢il..itiiil8i1i4iliY:.lSNl9ilieitititit6lagih/frl.ilYYililili9i*i4i!�L`�Tri�� BOARD OF HEALTH TOWN OF -BARNSTABLE Certificate Of Compliance THIS IS TO CERTIFY, That the Individual Well Constructed ( ), Altered ( ), or Repaired b Installer — { at= —-- �—---- ------------ -- -- — —=--—=---—has been installed in accor ancd a with the provisions of the Town of Barnstable Board of Health Private Well Protection g described in the application for Well Construction Permit s_�' _�5Dated--1 Regulation as describ i THE ISSUANCE,OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORY. DATE—_- _ Inspector--------- - -- — iliA4.la4Ll6bAiTiIYNYita0.i/LlitiltfilfAiYi.Ui�ili?6fiPlYli.4K iti2ili@il6leafi!iB�.lofiKTwOi9r9Y13!itil{NYIi!�i'+iPi?iiiY!iti4i�isi9Mi4NYTGTiIa?i!i!�!Y?i1Ti4Y..ilfYTsne!i�i!+! BOARD OF HEALTH TOWN OF BARNSTABLE Well Construction Permit ~� ASSESSORS MAP NO: f No. - ------- PARCEL NO: i Permission is hereby ranted to Construct ( ), Alter ( ), or Repaiir (L an Individual.Well at: r �" m.wjO _ _.— ,,/J�__—(• u/ O — . ----------------- —_------- J - Street.:---- ---- as shown, n the ap lic at'on for a Well Construction Permit ---------------- s ✓�No.- =- - � ��-- - DATE r' `�� P Board of Health i i 13S t�©: X s� Iv� i r No.-W-1 = - Fee------.5---------- BOARD OF HEALTH TOWN OF BARNSTABLE ApplicationArVell Con5truct ion Permit Application is hereby made for a permit to Construct ( ), Alter ( ), or Repair (V)an individual Well at: ^4IIJSr1C »ac�lj -- — -- Location — Address Assessors Map and Parcel 11— _ Owner Address -----—-------—-----— —— l°=�"`7X —��G� —` `s �``` —�-�e ---------------- Installer — Driller Address Type of Building Dwellinge -------------------------------------------- Other - Type of Building ----------- No. of Persons.-------------------------______ Type of Well iL f v C ---- - -------- 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 7)2'j —------- --- - "'PA-0 y--__- date Application Approved By— -__ --_______— b --0 .-?C/___ date Application Disapproved for the following reasons: ----— -- ---- ------------------------------ ------------------ date Permit No. Issued date BOARD OF HEALTH TOWN OF BARNSTABLE Certificate Of (Compliance THIS IS TO CERTIFY, That the Individual Well Constructed ( ), Altered ( ), or Repaired (-I by--- --- A Scu - ------------------------------------------------------ Installer _ -------------------------- -------------------- 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.VO = 1—Dated----- -------- THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORY. DATE----_____— Inspector----------_______ No.-W--- - ------ Fee--- ---5------- -- BOARD, OF HEALTH TOWN OF BARNSTABLE ~� Application,tIvell'.Con5tructionPermit Application/is /hie/reby m�fade.fora permit to Construct)( )., Alter ( A), or Repair ( n individual Well at: _— ,_----- .- - ' vraG_ capon Address M/!�narcel _1-)_ f 1{ -- Owner Address — n/� —J` o s��/.� L` ------------ Installer: - Driller - ---- — -------•.-- _._ Address { Type of Building Dwellin i(m.c e ------ ------------- { ' g — - Other - Type of Buil'id ng �-=~ ! - . .J , No. of PqsTns---- 1 -------------------- -- ---------- Type of Well if-t-�`� c --- - --- ---= Capacity-----` ---- - - - ---— Purpose of Agreement: The unq rsigned agrees to'install the aforedescribed individual well in accordance with the provisions of The Town of Barnstable Board.of;Healih. Priva��te Well Protection Regulation - The undersigned further agrees not to place the well in opL\Signed ation'until a�Certific to .of Compliance has been issued by the Board.of Health. =�� — - - — /ok-f-- - -- -L----- d�atoe, sg, Application Approved By -_ t� , ��1�kL7a :�o u�f Z ����I , date 3 j Application ---- u date i -} Permit No. �l _�=_g a -- Issued=---- --- aare.�:— ---- _- -, .. i .�Qi^.1iT}ai4dO"!►Y�l"+1'!- i}liiRY4i'Qifi^.�TiB�l6lil:rlplaF.F4ii'�i iXfo'Klii! Kl4Qd�dMi4I:MF6Sii489f�NiTitGYClnliY4al3`feli9ilwlQltlGli4G!�!ilbliN4.iwliMN�A��2;!i� BOARD OF HEALTH TOWN OF . BARNSTABLE c ertif irate of Compliante THIS IS TO CERTIFY, That the Individual Well Constructed ( ), Altered ( ), or Repaired (-I by Installer �' --— --- - �� S �4c /'ram S�ovv ��— P`__ --- -- — — — 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. 1 DATE------ - __ Inspector---=---- - - - -- ---—- 7�'�i.4�!i1ti34liSii16li4S/itit�lYlA�!6li4iVblGli4i�,6ti,Vili9Mb9iS.YRYL.YllilitiNlCi�itititGlitjylllyTilylYw�litblf!W9iNVipi}y�rill�.NQ�i�i�OTimi'i4iN!Yl.ifi!iTi��Nlili!S!41F.i4i� j. BOARD OF HEALTH TOWN OF BARNSTABLE Well Construct ion Permit No. �� t, Fee- -� Permission is hereby granted of — — ----— to Construct ( ), Alter ( ), or Repair(✓) an Individual Well at: .Street ---------- —----------- as shown on the application for a Well Construction Permit. No. _ --- Dated 1 �-�� -------- - -- - _-- -------------------- __...__ Board of Health t DATE - it , t