HomeMy WebLinkAbout0000 CHURCH STREET - Health (2) 0 cotunk SF. W . 6
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BOARD OF HEALTH
TOWN OF BARNSTABLE
Appiicat ion ArVell Con0ructionpermit
AppliZat'on is hereby made fora ermit to Construct (i), Alte ( ) or Repair ( )an in ' 'dual W 1 a
Location —�GAAddress�/ n Assessors Map aanndd Parcel
Owner ddress
f�i4 Do?�---S
Installer — Driller Address
Type of Building
Dwelling- --------------------------------------------------
Other - Type of Building - No. of Persons--------------
Type of Well
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 C rtificate of Compliance has been issued by the Board of Health. �/ Q
Signed
date
Application Approved By �--= •-44 -- -A _ __���__��____
—-----— —— date
Application Disapproved for the following reasons: -----------------------------_________—__---_—_
----------- --
---- ------------------------------------
C, date
Permit No. Issued----- -- - - - -- - -- ----
date
BOARD OF HEALTH
TOWN OF BARNSTABLE
Certificate Of Compliance
THIS IS TO CERTIFY, That the Indiiv-iid�ual Well Constructed (./j, Altered ( ), or Repairedof
( )
Installer
at—— 0 /yl
has been installed in accordance with the provisions of the Town of Barnstable Bogard of Health Private Well Protection
Regulation as described in the application for Well Construction Permit No. t- 7 87--_-Dated-----THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL
SYSTEM WIILLL FU�N�CTIION SATISFACTORY.
DATE—__!_9 o�T' 7 _ Inspector-------------------------- ---
Fee---Y�-------
BOARD OF HEALTH.
.TOWN " OF BARNSTABLE
r �
Application-*r Vell'Cow.5fruction Permit
'Application is hereby'made fora ermit to Construct Alter.( ) or Repair( )an individual Well at-
t Location r Address f ssessomMa .and Parcel
Owner (Address
Installer — Driller Address i
I' Type of Building
Dwelling is ,•, t
'r Other =Type of Building --- -- ----------- No. of Persons=-- - — - -- — ---------
Type of Well—-y � ---—__ `. Capacity-- -------
Purpose of Well------- ----------- ->- -------=--- --- t,'
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 By4 U -- - -----— d-
date
Application Disapproved for the following.reasons:------------------------------,---___�____._--_______
date--------
-
e t
Permit No. _— Issued—="---------- --
date
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t BOARD OF HEALTH
'r
TOWN OF BARNSTABLE
Certificate Of Compliance
THIS IS TO CERTIFY,,That the Individual Well C nstructed (/j� Altered ( ) or Repairedby-
( )'
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. ,tX 7T--=Dated----- ----
THE ISSUANCE OF THIS CERTIFICATE.-,SHALL NOT BE,�CONSTRUED AS A GUARANTEE THAT THE WELL
SYSTEM WILL FUNCTION SATISFACTORY.
9 9
i DATE.—---- -_ r Inspector --= - -- --- --------
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BOARD Of HEALTH
TOWN OF BARNSTABLE
Vell Con5tructionVermitNo. f
-- Fee
Permission is hereby granted
to Construct (/), Alter ( ); or Repair O an Individual Well at:
No. — 1 �" erg : a Str _—�-- —-- ---- — — — —
'
as shown on the application for a Well Construction Permit
No.- Dated--_ '=a`--L" ----------------------
Board of Health
DATE �� L� — �� ---
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