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HomeMy WebLinkAbout0010 CROCKER ROAD - Health /o C 0CkeV- R� --lens /ogr TOWN OF BARNSTABLE LOCATION I��1��/iIM�" SEWAGE # `73- 6 ��I VILLAGE �J11� ��c�LLr ASSESSORS MAP & LOT (� INSTALLER'S NAME & PHONE NO.t f SEPTIC TANK CAPACITY -,T ti LEACHING FACILITY:(type) Re 6"Asi (size) NO. OF BEDROOMS Rl)LATE W L OR PUBLIC WATER BUILDER OR OWNER 1 DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No (� i t 'k" t Uus 19/0 lVey 6'�� 0 • No.. ,3 s� `f FInt.......3e.......... APPROVED THE COMMONWEALTH OF MASSACHUSETTS _ BOARD OF HEALTH TOWN OF BARNSTABLE Appliratinn fur Dig pa!ial WorliB TomitrnrtinnPerm-it Application is hereby made for a Permit to Construct ( ) or Repair ( �, an Individual Sewage Disposal System at ........................... �'� '� �V j. r ................................ L :Lion-,]t 9dr-ss or Lot No. .... .... ...... _'ice r- G� -----------------------------•----- -------------------- AddrOencr ................. Installer Address Type of Building Size Lot............................Sq. feet ►., Dwelling— No. of Bedrooms--------------------------------------------Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( ) QOther�tur W Design Flow............5. .......................gallons per person per day. Total daily flow.7.':-;_C__._........,_..._.._...gallons. rx Septic Tank—Liquid capacity............gallons Length________________ Width...__._____-_-_. Diameter----- .......... Depth................ W Disposal Trench—No. ......:............. Width......_._._.__..__._ Total Length_._.___............. Total leaching area......_.............sq. ft. x - Seepage Pit No........./.......... Diameter.._...A0_-__. Depth below inlet...,.�f........ Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by..................... -----------------------------------------------•---- Date........................................ Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................ fTq Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ 9 --------------------------------•-•---•-------•---•----•---•-•----•--••-•••-----•-----------................................................................. 0 Description of Soil........................................................................................................................................................................ x x ---------•-•------------------- .............................................................................. ---- Nature of Repairs or Alterations—Answer when a licable._... _ .. �_...: !` :._ __. �Q/ �- ------------------------------------------ Gv�-e. 4 :......... � ..-r�.-l��" .--------._.........._.._........................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued y th rd of heal Signed .... ...... .... ......... ...... .....f - .... <.`..k ... �z.�^� Dace c Application Approved By ----- t,/ J _....... �1.: Dm Application Disapproved for the following reasons: ...................................... .. ................................................ .............................. ---------------------------- -------- ---------------------- -------- .----------- ........... .---- ..------ .---- .---- .............. .....---- .-------- ---------------- ............... ................... ..... ...... .----- .----- *... ..... ..... ........ Permit No. .........1:.,3--.`..---.�..P .L/.................... Issued ................................... ............... Date...... Dace .1""�S�.�J"L..vr�••-.ti,.--�...-..,.s.�,w-.,r. r_ ✓-aJ1�•"-_.�.._-.-�✓•--- �-��v..� v-+.�-�_..:1 -. ..-� a..-vay-J•-.+a. .�w-w v .+ ". 7 �! FEB..... - THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH t TOWN OF BARNSTABLE Appliration for Diripwial Wur1w Tomitrnrtiun rnmit Application is hereby made for a Permit to Construct ( ) or Repair ( van Individual Sewage Disposal System at: ,fl Locat ion-/:Yddrrss Lot No. l L r^Y Owncr y Address/ � Ln-��•---•-. .--a Installer ----- ' Addressr= ' _-l- PQ - dLot Type of Building Size Lot.___._•..___•-•-_--_-_•-_...Sq. feet i U Dwelling No. of Bedrooms-_-__--�7____________________ _ _ _Expansion Attic Garbage Grinder aOther—Type of Building ____________________________ No. of persons---------------------------- Showers ( ) — Cafeteria ( ) dOther fixtures_ _________________________________ _ W Design Flow............5..� .................gallons per person per day. Total daily flow_.2.C-).___.____._._...._..___gallons. 1:4 Septic Tank—Liquid capacity............gallons Length________________ Width---------------- Diameter................ Depth................ Disposal Trench—No_ ____________________ Width.................... Total Length.................... Total leaching area....................sq. ft. � l/7 Seepage Pit No---------�----------- Diameter____-;__.._-.-_...._ Depth below inlet-----..::........... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by........-................................................................. Date........................................ Test Pit No. I................mmutes per inch Depth of Test Pit.................... Depth to ground water------------------------ rz, Test Pit No:,2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ a ................................................ --•-•-•••......-----•-------•--••-•-•---•-•••. --•------•-----...•-•-••-•-•----••...............•------•-----•---•---......-•---....._....-----•......------ 0 Description of Soil..................................................................................................... -----------------•-•----•----------•---........._...-..-•-------•-- U ZW -•-•• -•---•-------------- .................................................................................................................... -••-••••-•-• ................... . U Nature of Repairs or Alterations—Answer when a licable._..-A�1 ht � FJ-__.."L.�___..� �..U P PP .......................................... _/_ `-2:_._._� f�>t<_._.._.. .... T 1-�c..._.�:_ Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code —The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of healV9 �N Signed .......................... v/` ! ----------- ................Dm�.. Application Approved By ----- -. -,.• ��.. .� �,t.," . .------...,. ... /.. 4.rl.'..- .. Dare Application Disapproved for the following reasons: ........... ......... ........................... .... .............. . ................................... C� / Dace Permit No. 1..��............2..v`�> .................. Issued ........--........................ Dare .ac----tea---ova----------:aas—x:————+w----.r—..--_-,---w.w------- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE TCrtifirate of 1011ompliaace THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired by .................. ........................... ....... �. C - . ..... r 1 C_ ..................._............. -.... .._.............-...-.........._..... laaall� I at ........... .........................._............ ................- .._.... ..... .. _.. ................... ......... has been installed in accordance with the provisions of TITLE 5 of The State Environmental Code as described in the application for Disposal Works Construction Permit No. ..._.�3.�..�...2_...------ dated ..._..._......_.._................. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNf TTII'ON SATISFACTORY. DATE ),I...'....t. _..._..t ` ! ...... _..................... Inspector .. ........... mac-•-a - ... .- -------®ate.--w. M-.r_--7- r----V-.-- --ti -a s vim.-a-.�.a THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Difiliniia1 Workii Tonlitrudiun Vantit 4 vl ,L-L-h Vf / 5���/ r C Permissionis hereby granted-----------------------------------�-•=........ ----------------------------o............................................................. to Construct ( ) or Repair ( an Individual Sewage- Disposal;System atNo......................................... ............�� G yam'i ...... Street as shown on the application for Disposal Works Construction Permit No.�....- Dated... ................................... ------------------------------------------------••-•-•••••- DATE..............f-�•--.../l--' ................................. Board of Health FORM 36508 HOBBS A WARREN.INC..PUBLISHERS 99 L O C AT 10 N /�/Pp�pf/J J SEWAGE �ERMIT NO.{\p, t vX 7 Y -7 VILLAGE f/m" - lU9 -OF- INSTA LLER'S NAME & ADDRESS &,/ tq z t 46 � , gdd:r�Vak B UILDE/JR OR OWNER 17 DATE `PERMIT ISSUED DATE COMPLIANCE ISSUED - ,� _ ' - � ` . r �{ � - - . . � �° � �. R ��, VIC- No.........A_.1..._....... Fss...............®.. THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH Oct Alipfira#ion for Dhipmal Vorkti Tomitruriinn ramit Application is hereby made for a Permit to Construct ( V) or Repair ( ) an Individual Sewage Disposal System at: ........ 1.0?.: �A.....:. .....� ---------------------------- ---------------- .j. ._..... ..._.........--......._. oc 'on-�1ddr ss or Lo No. _iA ............. Owner Addre s .............. `-- ...................................................... .......... Installer Address �- d Type of Buildin Size Lot.A:���_� �__�...Sq. feet U Dwelling 2No. of Bedroom s_______ _...............................Expansion Attic ( ) Garbage Grinder Other—Type T e of Building ...__..... ............. Showers — Cafeteria a yp g _..: No. of persons___._____ (� a Other fixtures -------------------------------• . .. w Design Flow........VS9.....................-------gallons per person per day. Total daily flow.._......t�0_.........................gallons. WSeptic Tank—Liquid capacity.=..gallons Length................ Width---------------- Diameter---------------- Depth................ x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. �,2- Seepage Pit No-------------- ...... Diameter.._... ��. Depth below inlet..... ... Total leaching area."4.....sq. ft. Z Other Distribution box ( v< Dosing ta� ) a Percolation Test Results Performed by..............�._........ fi-ON._KIS..._._._.._......_.... Date.......4.1_..�2. 78--__----. Test Pit No. 1----L 0.._._minutes per inch Depth of Test Pit-----10'"..... Depth to ground waterAQ__E......... Test Pit No. 2-----1 t.0....minutes per inch Depth of Test Pit-__-17.._......_.. Depth to ground water-_ftma-aw.COU + Ra' -•••-----------------•--•---•-•••••••---•..................-•••--••----•-••-.I--•----•-----.....--•.........-•---•-----•--••----•-•••.......--•----ti.= Description of Soil-h .-N0t'* :7:.q++LQA i.._12��-SA(�5�1_I•••-•-••••••••••---•--•••••-•--•-••-------------- � ••••••••••----•-••---•--•--••---•--•••••......•••••••------------------•--•----------------------------------------•-------------------•--•••----•--••. U l ��p ,--'�`_r.� a�+ rz�f .'.raruvxt..e�ed UNature of Repairs or Alterations—Ans er en pplica le______________________________________________________•-•---_----_-----•.------•-••_----_--_-. .......................................................... ------Z­--------------------------------------- --------e----- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLi: 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has b n issued by thVe bard f,health. Sn • ..... .r..--( ......................... Date Application Approved By... / 17`114 Date Application Disapproved for the following reasons:............ ..•----••••--•-••••••-•••-:..----....•-••-•-•-••••-•••-•-•---•-••--•--------•••--••••-•------_... .......................-........................................................................_.........--••••--•--•.....•••••---••----•-••-•-•-••••-••-••----------------------...---••-•-•--•----•--- y Date PermitNo......................................................... Issued_....................................................... Date 51 "�- =TH`I`COMMONWEALTH OF MASSACHUSETTS BOARD F" HEALTH -7 Q� . ........OF...... ....... '. �3.:.. �.'..................... Qlrrtifiratr of Tn mplinnrr T S TO CER Y, That the Individual Sewage Disposal System constructed ( ) 'or Repaired ( ) by ..... --•--. ...•--• --- ........... has been installed in accordance with the provisions of 5 of The State Sanitary ode described i the _/application for Disposal Works Construction Permit No ___-_ 7.................... dated_ :.._/Z--___7_k.:.... THE ISSUANCE OF THIS,, CERTIFICATE SHALL NOT BE CONSTRUED AS GUAR NTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE.........................---•--.................----•---•------•--••........---- Inspector.............................................................................I...... No. •- - ---- Fmc.............................. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH OF.......................................................................................... Applira#ion for Bh4paial Vorkg Tonarnrtiun ramit Application.is_li'-efeby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: ................to.­_-..`t-I..._ !' ..! opeo..----•---------------- --------------------.......Tq........ ------------------------------------------ 'Location Address or Lot No. Owner Ad ress a ................��........-kltP 1-------------------------......-•-•--......----•-...... .....�Apt ,..�T,. .....�I �. Installer Address Q Type of Buildin Size Lot.3&�_i�.O ....Sq. feet aDwelling No. of Bedrooms.........A.............................Expansion Attic ( ) Garbage Grinder ( ) Q, Other—Typ'e' of Building ....:....................... No. of persons............................ Showers ( ) — Cafeteria ( ) Other fixtures -------------------------------- - W Design Flow..............VS.D ..................gallons per person per day. Total daily flow____._...c3CO._-....................gallons. WSeptic Tank Liquid capacityADQ�allons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No._-_--_-._--_---- Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No..--------I......... Diameter.........4.._..... Depth below inlet_....._........ Total leaching area..>* .....sq. ft. Z Other Distribution box ( cl� Dosing tank ) Percolation Test-Result Performed by...._....�� :. I..-i 0KIK15..��...................... Date___4.1_IV�............. aTest Pit No. 1...._..+Q....minutes per inch Depth of Test Pit..��_•..-'..._.. Depth to ground water).0W.- (i Test Pit No. 2.....I%Q....minutes per inch Depth of Test Pit---IZ'¢___.... Depth to ground waterMWA..--- 11N7RD a --••--. ------•----------•-••-.....-•-•-••••-••••-•............................••-•-••••--••----------................-•••-••--•.•-- ------......•--- D Description ofSoil P.... r/.....-+---4-�'. U ?7� 12��- 0/LtQ2! ome -sA�U --S{�, NQ ..-_•-1t#J e.... DI p...............................................................-------r-------------- ----- ----.. ...--•---------.•......•................................. PtT ,..l.f._�U� 71. �. 7 CQA ._ 1�.f 'a_G --.�_3.. t 11 '� 11u� U Nature of Repairs or Alterations—Answer when applicable............................................................................................... •-------------------------------------------------------------------------------------------------•-----...------------------------------------------------------------------....--•••-••....-••-.-••••. 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 operation until a Certificate of Compliance has be sue by the boa d of health. S ...114C -••-•----•--•---•--•----•....... at / Application Approved By-- �%� � Application Disapproved for the following reasons----------------------.::!X_.........------------...--------------------------__....-•_______.--•Date---........... J Date PermitNo.......................................................-- -" Issued_....................................................... Date THE COMMONWEALTH-OF MASSACHUSETTS BOARD HEALTH 00 ........OF....... ..:. ......... . . .... Tntifiratr of TTaant�fianrr TT S TO CER . Y, That the Individual Sewage Disposal System constructed ( ) or Repaired ( ) by......... ....... • -•---------------------- •--------... ..... •---.-..------ . Installe ` t .... -- ----... --------- has been installed in accordance with the provisions of T yj of The State SanitaraUA described i the application for Disposal Works Construction Permit No. ...._7-�7-_--------_ dated ---�7 7 THE ISSUANCE, OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS TEE THAT THE SYSTEM ,WILL FUNCTION SATISFA- ORy.' DATE..............•--.............. ......... Inspector.... THE COMMOk�ALIN OF-MASSACHUSETTS ?b� 00AP�D 0jY HEALT ............. ... .......OF.......... .. ....._...t............... FEE �`S...... No. ...`�.............. e`°x Permission is hereby granted...`...... s---------------------------------------------------- to Cons (' orPair�x, ) an i 1 w Dispos yst4 at No.. •` ..2rft . ...__.. "'�'' ... - t ..... •- • .' 'ti reet c' wA as shown on the application for Disposal,Works Construction r it No ;�..:. _ Dated..-.7-.._..r....y.................. • /f 0 ........................ B and of 100/1 DATE......°-•-------•••-•---•••••-••••-•---•••--•-••••••.........•-•••.-•••-...---- FORM 1255 HOBBS & WARREN. INC:. PUBLISHERS., 3 .X..�....._ - 'qi i f►'+ I 4 Mi rA � -_ --_ _�+Yw,. -.-.ice.-. :�-r_...�..w � ... . - -.._.w� d� • f I , �nwa'•mot- -�•U � i 7 �f� • r�s�- t 4&AC44, � t ao Q , tv r i. V+ / n tee#+ 9 OUT d, N 35,I S o S% F• 4 o - J Of 1,4 1 d Lv t o ROBERT, 7,S.o 0 � � P. ` �l. U toe14/ v BUIN,IKISNo.22161 y k'O!i ' Gf�0 GOl IZ ONAL LEGEND EXISTING SPOT ELEVATION 0:0 C R I E D PLOT PLAN EXISTING CONTOUR -- - 0 - -� L07- 9 CR0c ` z R©A r-> FINISHED SPOT ELEVATION FIWISHED CONTOUR 0 iia/�s7-_,�'�►_�usr,�-�t.� AP ROVED , BOARD OF HEALTH a _ �A.4vs mmLgomAs& DATE AGENT _ SCALE: / =4� DATE : /3 /71- CLIENT L©�rsOGE EMGIAIEERIi!!G CQ IM �1--I t CERTIFY THAT Tl�� PROPOSED _.._._. C�Gi3YER2 REGISTERED jOB fd0 7ec /4-, 3UILDING SHOt"id ON THIS PLAN CIVIL LAND CONFORMS TO THE ZONING LAWS GINEER SURVEYOR DR.BY: 21• 4kAl p+- 0ARidSi 0LE MASS. 33 NO. MAIN ST lt2 MAIN ST. CH. BY: J�. 1 3' ` ,317E1� S0. YARM.IOU'['tt, MASS. NYANNI$, MASS. � / �- Z � � --- IS-, 00= U .Y� REG. LAND SURVEYOR �• 20 FT. M/N. NOTF � /F E/TNteR ?'s/E SEPTIC TA�/k [}/,� GE/9CNIiYG Oir .417a'»� /►'JpRE rNAIV /O PT M/N. �►�'p/AM ETER C®NG'RETE CoV CONcaere '�"Pvc I' . S/yAGL e,E ,fitROUCSNT Td 4RAO,E.�.qN/-/E.4VY CA 5T/RO/V C0V,—R Sf, q L B,E !/SEloA9/N. P/ti :o • CODERS IF•//y pRIVEANAy B <1 Z% A/ilV. CO/VC&4-TE CC)Y`E/4 CL FAN -TA N 0 �. LIQUID LEVEL 8AC/C/c/LL ' 4"CAS IRON P'/PE LAYER M/N. P/TC/1 GG<i GAL. �o •e o a G1F 8" P&R PT• SEPTIC TANK D I ST, o e 1 • • • o • e i i n e4 WA 5HFD 577OA14 a � BOX o P p • 1 $ e o 0 0 • A°D 04 - .. •. t D 1 1 OEF'PELT•/✓E • ° ♦ � 3�4 n- f �.$��' � _ •.,,; a v 1 ' DEPTe o e � I v � y✓�J 8HE0 STi?M�• o ` a 1 v0 y o e I I • • o o e • / • o n o o a • • o 0 0 • • i • p o p — PRECfa5 T SEE-pA6 r !N!/E'!ZT ErLEb�ATIONS v ► o • 1 • s • • • • a ` o P/T OR EQLI/V, lNYERT AT BUILDING !r1 6,0 fNLET SEPTIC T.4ArK `I S S FT FE LG_'F7: D/AM. C(SEE rA&L//-AT/4/v, OUTLET SEPT/C TANK 5.3 Fr VNL,ET 41P/57R/A91/TIoN BOX 95,OFT. SECT/pN OF GROUND WATE)Cr TABLE O/JTLETD/STR/®V-rlON BOX 9. 4,9 F7. //VLE�'SEEPA�.sE P/T 94_o FT. SP�/s4GE L7/.��Ou''.4 l SYST.�M ,LFACEN/NG A/T 7A' 8YJL.A7'140yV 7'EFP/A SCALE : %¢" _ /= o" OlAfeN.F10AI A D1MONSIO" NUpOBER OF 9EDR0pI+9,s 3 DtMENSlON C�_FT �,N G4R4SA0Z,&15P05ai- SO/L.. LOG TOTAL LS3T/~'TEp FLO*v 3 O O G,44.1,pAV SOIL TEST A/ SOIL 7-,--S7-02 'S®/Z TEST AlUN�BER aFSEEl�i6E pins_ L 1-F4ev_ 97, �`^ErL� - 93 .0 pgT, S/ c 8F So6L TEEST �Si4► Z�? DE LEACHING i''ER P!T f rr� SQ, FT. d 607TOM LC,a4CH/NG PEFR P/r -'i 8� S• FT (rO'4'/`I f2E5ULTS W/TN.-sSFD BY R•��6/af//ter 5 TOTAL LEjACH/NG 4REA Z b 6 SQ F!; /Z vjro sdct �aeO'C' R'4ra AP/ I I�91N�I/NCN �dST6Rb'E C64C/�IlN6 AREA 2-•U b SQ. FT. z'CDatzSc- S vA,SOrL PZlZC0LA-r10 Y RA7`,S o•2 !.V MIA/. /NCN ss�-*ire � cc�n-rash 7 • 'sue-+✓r� 6�. 3►`� s°o 4 s�o,vn & /i•�•rs GO' T' 8 4=lzo ROSERT �k cz BUNIKIS '*&rr; A�Als-r,413 � tta22162 4 1✓�fiT� WlflTt _ �b�FaISTE '`@ N O, 5�►/ "a.1L.6?*q&'®0&eA0,1 A FZ.MAZ 4 9.,1AAc . . OVAL��6 FL. Fri►.?1 �L $ f•e� _ 71Z Jt:A/hV,air:- M N®GRCV VP w,4 mw ClNCC4U/VT v7rep P HY,4,VNI.7, MASS. S� �'A Q/�.rT,Y• �Ro uA o 2-/A I �^I,? AT No.--- 149 Fee— ---- .--------- BOARD OF HEALTH TOWN OF BARNSTABLE ZippYicationArIftl Con9truction ermit Applicati n is hereby made f r pe i to onst)r�u jtt ) All ( ), or Repair ( )an individual Well at: Location Ad s Assessors Map an` P cel 014 op —a— -- ----- -- — Owner Address Type of Building Installer —"Driller Address Y G Dwelling-------------— -- — -- -- ---— - Other - Type of Building---------------------- No. of Persons--------------------- ---- T e of Well--- -PY —'-- --��� '!�'t `= --- Capacity------------ YP — — -- -- - ___—- — --- 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 He lth Private Well Protection Regulation — The undersigned further agrees not to place the well in operation unti Certificate of CCompliance>h s been issued by the Board of Health. Signe - -(-- _—_ — --- — (,> — date Application Approved By - - ----- T — --- date Application Disapproved for the following reason :--------Vj -------___________—_�_� date Permit No. , --- ------- - Issued-----___! ��%_—_-------------____-- /date t - _ No.V-qu�--.—•�i Fee-_'-� BOARD OF HEALTH TOWN OF BARNSTABLE ZIppIication-*rVell (tow5tructionVermit Application is hereby made f,o r a per i to Construct ( ) Al er ( ), or Repair ( )an individual Well at: - 04 It p Location A dress Asses Ma an P cel A -- --------------------------------------------- —— — — `--- Owner Address t _1 "="-------- Inst°aller — Driller Address Type of Building pE Dwelling ' -------------------------------------- -- I Other - T e of Buildin --1----- No. of Persons=` "' - -------------------------------- YP, g- - �r CA.tc c Type of Well------�Y---�-- �-- � - ---- - - Capacity---------------------------------------------------------------------------- - Purpose of Wellr. -�-----I--------------------------------- 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 untj ja Certificate of Compliance 4hns been issued by the Board of Health. ,�,'�' L date /�f Application Approved By -AK� ------ V-"'- '�'�' � r-� date .: A e Application Disapproved for the following reasons:---- - =------------------------ -------------------------------------- ---—-----_--__---------------------------------------------------- - ---- date Permit No.- -- Issued - - ---� �tdat l -- i e BOARD OF HEALTH TOWN OF BARNISTABLE, (Certificate ®f Compliance THIS IS TO CERTIFY, That the Individual Well Constructed (��), Altered( ), or Repaired ( ) [ - / by - 4- - - -- Installer 10 s - - - has been installed in accordance with the provisions of the Town of Barnstable Board f Health Private Well Protection < c � -- a Regulation as described in the application for Well Construction Permit No. -- ----------{------Dated- 7-��..- - THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORY. DATE------ I•nspetor , ------------------- r. .�.. <. .. - 4 v. Yet a BOARD OF HEALTH jY TOWN OF BARNISTABLE Vell Construction ftmit 3 No.--;------r--------- Fee- < 1 � Permission is hereby granted------ - -- ----------t-k ------------------------------------------------------------------ 4i to Construct ( Alter ( ), o�r^R/e�pair (p) an IInj�iovikacoxc3dual Well at: �) j /� ,�/ No. - _6fiulll- -R as shown qn the application for a Well Construction Peltnit "L -- Dated— .._I1) l_-- No.- r ---- 7 � _ - - j . ., ----------- ----- l ,r-------_-- Boar1f Health DATE------ r - ------------------------------------ ciOf