HomeMy WebLinkAbout0041 CROCKER ROAD - Health (2) 41 CROCKER Y'
_ 'WEST.BARNSTABLE
A = 109 041
a .
/ TOWN OF BARNSTABLE I/
LOCATION S �/�.[rr+ ara ,ICY SEWAGE #Qj -5D5
VILLAGE ASSESSOR'S MAP LOT 61.G q y
INSTALLER'S NAME & PHONE NO.- ;Lv �`mac c� ,w:. 44rel,
SEPTIC TANK CAPACITY )Qp`)..o►.t�1[
LEACHING FACILITY:(type) y jAj; -j Y,�lc size)
NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER
BUILDER
DATE PERMIT ISSUED:
DATE COMPLIANCE ISSUED:
VARIANCE GRANTED: Yes No �/
1
V.3
S 3"
GS 63�
�M. CERTIFICATE ' OF ANALYSIS Page 1
Barnstable County Health Laboratory
Report Dated: 12/3/2004
Report Prepared For:
Order No.: G0428729
Lena Mahler
41 Crocker Road
West Barnstable, MA 02668-1215
Laboratory ID#: 0428729-01 Description: Water-Drinking Water
Sample#: 28729 Sampling Location Al Crocker Road West Barnstable MA Collected: 11/29/2004
Collected by: L.Mahler Received: 11/29/2004
Routine
ITEM RESULT UNITS RL MCL Method# Tested
LAB: Inorganics
Nitrate as Nitrogen 2.6 mg/L 0.1 10 EPA 300.0 11/29/2004
LAB: Metals
Copper BRL mg/L 0.1 1.3 SM 3111B 11/30/2004
Iron 0.10 mg/L 0.1 0.3 SM 311113 11/30/2004
Sodium 17 mg/L 1.0 20 SM 3111B 11/30/2004
LAB: Microbiology
Total Coliform Absent P/A 0 Absent 307 11/29/2004
LAB: Physical Chemistry
Conductance 260 umohs/cm 1 EPA 120.1 11/29/2004
PH 7.2 pH-units 0 EPA 150.1 11/29/2004
Based on the results of the parameters tested,the water is suitable for drinking,but may present aesthetic problems(taste,
odor,staining)due to Iron.
Approved By:
(La Director)
QIDUPLICATE
RL = Reporting Limit
MCL=Maximum Contaminant Level
Superior Court House, PO.Box 427, Barnstable, MA 02630 Ph: 508-375-6605
�I - �.—
No... .............. CL A
Fizi3 .....
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE �/
Appliration for Uiopooa1 Works Tonitrnrtion ramit
Application is hereby made for a Permit to Construct Kor Rep �1i' I k�hGIye Dis�posal
Sy tem a15 TACLATION AND �T SUPERVISE
---� � ._ > ....1 \, .v` a...........� I Y ASCSYSTEM
Y M WAS WRITING
THESTE INS Fy IN G
'tErifN. 4N'3TRIC
` , T
.......b.V ....—11.� I_.Mn A .. •.... .. ............•........... .....................--.......................---.................---•--•.........................
Owner Address
Installer Address
Type of Building Size Lot............................Sq. feet
Dwelling—No. of Bedrooms..S�_ .................................Expansion Attic ( ) Garbage Grinder ( )
Other—Type T e of Building No. of persons............................ Showers
C4 YP g ---------------------------- P ( ) — Cafeteria ( )
Other fixtures) --- ----- ------ --------- --- ---- ---
g allons per person per day. Total daily flow.. Ions.
W Design Flow....... ec... .� -
WSeptic Tank—Liquid capacity Xallons Length................ Width................ Diameter................ Depth..........
x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No.----------•I-------- Diameter.................... Depth below inlet.................... 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........................
44 Test Pit No. 2................minutes per inch Depth of T's Pi ..... Depth to ground water........................
oSoil3 � --------------•--•------.---•-•• ---•--. --------
Descriptionof ----•---••---------------------------••----.................--•--------------•--•--•----••------. •.----------•--•._----- ...----
U ---------------•------....-•••--------......-----------------------------------•--••------------ --- -• . ................
UW -----------------------------------------------------•--•-----•----•---•---•----. --------•--•......-------------------•---------•--•........_.......
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 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 health.
c ;
ASigned .. j x ,
Application Approved B bate
Date
Application Disapproved for the foPllowing reasons• ----------------------------------------------------- ------- ------------------------------- ------------------------
---------------- ---g....a-----_- �j .........................................................------------------------............. ---------- ---I................. ---........ ...
Permit No. 1 ......... Issued ...... . � / 1 -
Date
Dare
THE COMMONWEALTH OF MASSACHUSELT@IGNING 1=1VGINESR
BOARD OF HEALTH INSTALLATION AND CERTIFY IN WR TINGr THE SYSTEM WAS INSTALLED IN STRICT
TOWN OF BARlRNSTABLASCORDANCE TO PLAN,
(gertilfi.CM#E of Compli2 are :
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
by --------------------------------------------
Installer
at1 .. G A. ----------.............................................................
has been installed in accordance with the provisions of T�TLE 5 f he St E ronmental Code as described in
the application for Disposal Works Construction Permit No. ' dated .............................................--
SHALL T BCONSTRUED A A GUARANTEE THAT THE
THE ISSUANCE OF THIS CERTIFICATE SHA NO S
i
SYSTEM WILL FUNCTION AT IS ACTORY.
DATE.................................... ..- -- .............----------------- Inspector ........-- --------. ...---------------.... . .------------.
I � /
l� Fps.... , ._........._....
nn THE COMMONWEALTH OF MASSACHUSETTS
V BOARD OF HEALTH
TOWN OF BARNSTABLE
Appliration for 13ispnstt1 Works Tonstrurtion 1krutit
Application is hereby made for a Permit to Construct X,or Repair ( ) an Individual Sewage Disposal
.�stetn /� Lo -on Addle s - - -or Lot No.
�� _-_-- l.M....-�'17,�.. �......_...............
Owner Address
W
Installer Address
Type of Building Size Lot---------------------------Sq. feet
,., Dwelling—No. of Bedrooms_ 3----------------------•-___--__--Expansion Attic ( ) Garbage Grinder ( )
Other—T e of Building No. of persons............................ Showers — Cafeteria
Otherfixture ' ---------------------------------•---------------------------------------------------------•-•-- If^
W Design Flow allons per person per day. Total daily flow------------------ ® '-.- ......._gallons.
WSeptic Tank—Liquid capacity_,__- gallons Length................ Width................ Diameter................ Depth................
x Disposal Trench—No .... ...... Width................... Total Length.................... Total leaching area--------------------sq. ft.
3 Seepage Pit No---------_�_____._ Diameter.................... Depth below inlet.................... Total leaching area------------------sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
aPercolation Test Results ! Performed by.......................................................................... Date----------------------------------------
Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water.........................
a Test Pit No.�2................minutes per inch Depth of Test#Pit---_-----_---_--_- Depth to ground water........................
. -7T-f,�!1w!� - - ?C..!.....................•-------..............................�� -
.�_/�_viv a
0 Description of Soil.............. ---••-..---------------------•....------------------------------------ ----- ---------------------- ------------------------
�.__.. ? J � fib-- ---!I - /----�-------------
x ----•-----------------------------••----•-------------•----------------------------------------- --A�----------------�----------------------------------_----
U Nature of Repairs or Alterations—Answer when applicable.................../ ___----..-_..------_--//-_-_-___--------------------------------------
---------------------------------------------------------------------------------------------------------------------------1 ----_-----------------------------------.--------------------------
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 health.
Signed --m..�-�-f.?�'�-- -- - - '�!�-'�----�---�-----�------------- ----------------------------------------
- - - -- Date
Application Approved B .. ...
PP PP Y - - ----
. - bate
Application Disapproved for the following reasons: -------------------------------------------------------------------------------------- '-----------------------------------------
n �7 �j--------------
Permit No. ,/ �--------------- Issued ----- -// �------. Date
¢/ -
/ --- -Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
TPrtiftrate of Cfomylian e
t
THIS IS TO CERTIFY, That the Individual Sewage Disposal.System constructed ( ) or Repairedby ( )
---- ---------------- - Install- ^.
- ------------------------------------------- -------------- - ....................
-------------
at --.----
. Installer j�
..........
has been installed in accordance with the provisions of TITLE 5 f The St tvnElavironmental Code as described in
the application for Disposal Works Construction Permit No. ----�/ -'', ��a!=- .... dated ------------------------------- ..............
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS GUARANTEE THAT THE
SYSTEM WILL FUNCTI t TIS ACTORY.
I ,
DATE------------------------------------ �� = Inspector ----------------------------------------------------------
THE COMMONWEALTH OF MASSACHUSETTS
i BOARD OF- HEALTH
� � TOWN OF BARNSTABLE
No...�.......-..;.... Fn........................
�i���a��t1 nrk� �un��rnr#iun ��ernti�
Permission is hereby granted_........ ...........................
to Construct or))Re air ,an Individual Sewage Disposal y l� `
at No : L. �
_ . t..__ �5/') (-- ( --6l G.............. -�� -I --_-- --.......... ...............................................................
t Street ated_!O/�XI :�as shown on the application for Disposal Works Construction Permit No. /D , : N � .-----
-----•----------------- --------------------------------------•----------------------
_ Board of Health
DATE......................... ---------------------`--- ................
FORM 36508 HOBBS R WARREN,INC.,PUBLISHERS
ENVIROTECH LABORATORIES
Mass. Cert. #:MA063
449 Route 130 Sandwich, MA 02563 • (508) 888-6460
CLIENT: Mr. Richard Mahler LOCATION: Lot 30 Crocker rd.
ADDRESS: 308 Nye Road N. Barnstable
Centerville, MA 02632
COLLECTED BY: Desmond SAMPLE DATE:10-7-92 TIME: 12:OOPM
DATE RECEIVED:10-7-92 SAMPLE ID:VOC-1
JOB #: WELL DEPTH: 125'/80'
RESULTS OF ANALYSIS:
Parameter Units Recommended limit Result
Coliform bacteria/100 ml (MF Method) 0 0
pH pH units 6.0-8.5 6.11
Conductance umhos/cm 500 113
Sodium mg/L 20.0
- 13.8
Nitrate-N mg/L 10.0 1.24
Iron mg/L 0.3
n n6
Manganese mg/L 0.05
Hardness mg/L as CaCO3 500
Sulfate mg/L 250
Potassium mg/L 20.0
Alkalinity mg/L 200
Chloride mg/L 250
Turbidity NTU 5.0
Color APC units 15.0
Background bacteria
FPA 6n1/6ng None detected
COMMENT:yY See attached.
,ems No WATER IS SUITABLE FOR DRINKING PURPOSES FOR PARAMETERS TESTED.
nX
DATE �0 2�
GROUNDWATER
ANALYTICAL
EPA METHODS 601 and 602
Volatile Organics (GC/PID/ELCD)
Field ID: Lot 30 Crocker Rd Lab ID: 3885-01
Project: Mahler Batch ID: VHA-1077-W
Client: Envirotech Sampled: 10-07-92
Cont/Prsv: 40ml VOA Vial/NaHSO4 Cool Received: 10-09-92
Matrix: Aqueous Analyzed: 10-20-92
PARAMETER CONCENTRATION REPORTING LIMIT
(ug/L) (ug/L)
Dichlorodifluoromethane BRL 5
Chloromethane BRL 1
Vinyl Chloride BRL 1
Bromomethane BRL 5
Chloroethane BRL 1
Trichlorofluoromethane BRL 1
1,1-Dichloroethene BRL 1
Methylene Chloride BRL 1
trans-1,2-Dichloroethene BRL 1
] ,I-Dichloroethane BRL 1
cis-1,2-Dichloroethene * BRL 1
Chloroform BRL 1
1,1,1-Trichloroethane BRL 1
Carbon Tetrachloride BRL 1
Benzene BRL 1
1,2-Dichloroethane BRL 1
Trichloroethene BRL 1
1,2-Dichloropropane BRL 1
Bromodichloromethane BRL 1
2-Chloroethylvinyl Ether BRL 1
trans-1,3-Dichloropropene BRL 1
Toluene BRL 1
cis-1,3-Dichloropropene BRL 1
'1,1,2-Trichloroethane BRL 1
Tetrachloroethene BRL 1
.'Dibromochloromethane BRL 1
Chlorobenzene BRL 1
Ethylbenzene BRL i
m+p-Xylene * BRL 1
o-Xylene * BRL 1
Bromoform BRL 1
1,1,2,2-Tetrachloroethane BRL 1
1,3-Dichlorobenzene BRL 1
1,4-Dichlorobenzene BRL 1
1,2-Dichlorobenzene BRL 1
QC SURROGATE COMPOUND SPIKED MEASURED RECOVERY QC LIMITS
Bromochloromethane 30 33 ill % 83 - 117 %
Fluorobenzene 30 30 102 % 87 - 113 %
BRL = Below Reporting Limit. * Non-target compound. Method References: Method 601 - Purgeable
Halocarbons and Method 602 - Purgeable Aromatics, 40 C.F.R. 136, Appendix A (1986).
THE T TOWN OF BARNSTABLE
OFFICE OF
t BAE39TsaL i BOARD OF HEALTH
,ems MAN& 0
oOAO mix". 367 MAIN STREET
HYANNIS, MASS.02601
November 13, 1991
Richard Mahler
75 Old Toll Road
West Barnstable, MA 02668
Dear Mr. Mahler:
You are granted a variance to install an onsite sewage disposal leaching pit
123 feet from the proposed onsite well, with the reserve 115 feet from the
proposed well, in lieu of the required 150 feet, on your property at Lot 30
Crocker Road, West Barnstable. You are also granted a variance from the
Board of Health "40,000 Square Feet" Regulation with the following conditions:
(1) All other regulations contained in Title 5: of the State Environmental
Code and Town Health Regulations must be complied with.
(2) The well water must be tested bacteriologically, chemically, and for
volatile organics prior to the issuance of a building permit. The water
must meet all of the standards established by the Safe Drinking Act
of 1974, revised 1986 and 1990, and of all the Town of Barnstable Board
of Health Private Well Regulations effective June 1, 1989.
(3) The dwelling cannot contain more than three (3) bedrooms. Dens, study
rooms, playrooms, enclosed porches, sleeping lofts, finished cellars and
similar type rooms are considered bedrooms according to the Department
of Environmental Protection.
(4) The system must be installed in strict accordance to the submitted plans
dated August 24, 1989.
(5) The designing engineer shall supervise the installation of the onsite sewage
disposal system and shall certify in writing to the Board the system was
installed in strict accordance to the submitted plan.
(6) The onsite sewage disposal system shall be pumped at least once every
three (3) years and certification of the pumping submitted to the Board
by a licensed septage hauler.
Very truly yours,
osep�C. Snow, M.D. ' ~
Chairman
BOARD OF HEALTH
TOWN OF BARNSTABLE
JCS/bcs
ZONE AF Revl 5lo+-3S
�'�� / 3.lZ.et3 L���R QRoposf�� LEA►-G�a ""'
pl-r B�Lvw vusv YAQy •rof coz,C.Bou�-.,n
FRONTAGE 150 Q•M, ASsuMev
FRONT YARD 30 ' %oIL rtv� sEp'C L pipE
SIDE YARD ' 15' i�.►Ta ` E-L. too.00
EXtSTt>J6
REAR YARD 15 D cAsci, -
MINIMUM AREA0 m
43, 560 S.F. �A P�6 0.00 160.0
�K10
C�0 �SOE �: ��.o� w E�"�G 's
�5 r `00
0 '3C
4 00 $r cmn
Aty
d oIN
w
APMOk,MA1E
o� - I guRt�b SYuMpS
Nb FILL
� "OF
160•
MI o
^�o PAULR �N / OQ
e� m
icrcy NCIVIL
o.30420 2 to 00.,..
/ .
8 •
0401
1
4990r
p
he
SCALE 1° = 40' EX'�G
wr�t_I.
PROPOSED SEPTIC DESIGN Pyj�tP H
� flCLf sURYfYINC Q fNG/NffR/NC,INC. ��i"9'�L/Y
L O T 30 44t Rca�e /.�D
C ROGKEFR r"ZOATD scndrtch. LIc. .OP66d
W• t3��t�15T/+'i��� ,1Jti,�, � (soe� sga-osss
i
TOP O� Fa �1S�sz5 SI�'/'a L�Z ��
SD I L TEST P I T DATA
F 1 N l�v}-1 GI�PIT�E FZ�{�R d F30US !lV01 CATES I ND I CATES �—
EE $-,pp ACCESS COVERS MUST TEST .
ION OBSERVED
L = I
s�� TEST GROUNDWATER
BE N,THIN 12 OF BARNSTABLE NO: P=� 3 84
F G--$2.0 F6. 4,0 I NI SHED GRADE
4' PVC ^co+-'G. ��4�sts MIN. OF Tpw �J TPw 4'
S�ONEWASH GRND.EL. �'® GRND.EL
SC4,EDULE 40 83.r_y�f� No+�E G. W.EL.NOSE
��O GAL. -19.60 Y� 14q - II/2- G. W.EL.
433•So SEPTIC TANK 8 O 1 6, �' STONE SHED
56 ,d FILL FVLL I
10' MIN.
lr�l. ri►-�R13�e 3.0' EL62.0
PR F E : NOT TO SCALE ORIGINA L
L_�O 4.0� El 5�•D
TOP-SOIL
[ - - -ra?aw L SUB'S o1 L
�OZ ROGEPAU R y�
- 0 MICHN E WJC2 INVERT ELEVATIONSSS.S
®ES 1 t CR 1 TER I A • .� No.304z0
CIVIL INVERT AT BUILDING 4'Ov— 7.5 EL fiS, CLCAM
DESIGN FLOW; . � �o F� -
3 •g(7 CLcAta
BEDROOMS AT 110 G. P. D . IA ;z I NVERT I N . SEPTIC TANK 5 A��
� a
BEDROOM EQUALS ®_G. P. INVERT OUT SEPTIC TANK : 90 ��
y� . � S O.O O SA�S'D
NP GARBAGE GRINDER v � INVERT i N D I ST BOX
I NVERT OUT D I ST BOX -7 �50 ;2. ti2.5'
SEPTIC TANK• REQU I RED INVERT I N LEACH P I T
�3(Z_G. P.D. X 1507 _ �'`j _GAL. 1 BOTTOM OF LEACH PIT DATE.
SEPT I C TANK PROV I DED : 1 000 GAL OBSERVED GRND WATER TEST BY: �11G1-iW1"415ZIFE
SIZE OF LEACHING FACILITY r, ADJUSTED GRND WATER ,_--
WITNESSED By:
Lli o'er•, SO)LS M 0.t r 15e, PERC. RATE: 2- MIN/INCH
REQUIRED 330 GAL/DAY LEY QG- ROPOSED SEPTIC DESIGN
DESIGN PERC RATE = Z MIN/INCH Ar`T- `r7� � G �
f, c> auf fWr C- ,
REVISIONS 3®
PROVIDED 1 - 4 P I T( S ) W/_4 STN
NO. D ATE REV 1 S I ON C R O C�Ce.R �O h•17 -
S I DEWALL :,1 S.F. X Z-5 _345 GPD _ -
I BOTTOM 3 S.F. X 1 ® 1 3 GPD _ C — trn w _' S(IRVLYIiVG �! L`'�f'CIiYBL'R/NC,lNc.
—+- — 44! forte !10
2.. TOTAL Z5 1 S.F. 5S GPD
NO. F I EZ D CALC: ORN _._
I CHECK : I SHOT 2 OF 3 (S08J 88B-06S9-
------ --- --__.__— --- ----------------
SOIL TEST PI T DATA 1
1 NO I CA I ND/CA T -�-
GENERAL NOTES PERCOLATION 0, DIC 0S
TEST GROUNO!✓ATER
THIS PLAN IS FOR THE DESIGN AND BARNSTABL E No: P- �38 Q
CONSTRUCTION OF THE SEWAGE DISPOSAL ,Q �
TP d Z
TP i,
FACILITY ONLY. GRNO.EL. G 1 ,O GRNO.EL G 3.0
G. W.EL. NOW?- G. W.EL. MOW9
r
2. ALL CONSTRUCTION METHODS AND
MATERIALS FOR THE SEPTIC SYSTEM
SHALL CONFORM TO MASS-. D .E. O.E. Fit-L SArnE
TITLE 5 AND LOCAL BOARD OF A5
HEALTH REGULATIONS. 8 R�1+tC.t� i 7P
ST131't'P$
3. ALL SEPTIC SYSTEM COMPONENTS LOCATED 'OL5i'D ;
UNDER PAVEMENT SHALL BE DESIGNED, TO 1LY
So t
WITHSTAND H-20 LOADING.
4. ALL SEWER PIPE SHALL BE SCHEDULE
40 OR APPROVED EQUAL. i
5. BEFORE CONSTRUCTION CALL "DIG-SAFE" 12 t
1 -800-322-4844 FOR LOCATION OF
UNDERGROUND UTILITIES.
OATE: �- ' g�'
TEST BY:-R . MI CIA N)r wIGZLP.E .
6. VERTICAL DATUM 18 WITNESSED BY:-G. t>L)y_AgikSG
7. BENCH MARK USED PERC.RA TE: MIN/INCH
B. FOR BENCH MARKS SET SEE SITE PLAN:'
M ;OGER
PAU L
`j. FOUMDA-TION DE•SIGIQ FQR PK0'P05ETD NIEWICZ
304
Dom,!ELL1 i.1F� 1 S 6`t OTH�ti�S me:,µ c , °a
�
•:� i o. �Et L.- 5�''P'�1 G L 5::�,Gi-) �t"�' VA,��AI�.tG� a� �y�� �� N �, �-�
zy. �9
SHEET 3 OF 3
No.- 'Y--/`- ----L--[ Fee----- --------------
BOARD OF HEALTH
TOWN OF BARNSTABLE
Zppritation-*rVell itontruttionA9ermit
A plication is hereby m e for permit to Coyrict ), lter ( ), or Repair ( )an individual Well at:
Location — Add ss Assessors Map and Parcel
E'er- -------- - --` °f3-'= —
/, Owne _ Address
G(/Ly/f _ �C.G�it/ --4ivL' _ �i2 ®iC'G��?•VS /�Q
Installer — Driller Address
Type of Building
Dwelling — — -— - -- —----- - -
Other - Type of Building-----T--------`_______ No. of Persons-_---____—_—__—_________
Type of Well- �n—/ 'S�o -'°12= a G—ST �cC"11 �PPCapacity---- -fJ—f ��s—
Purpose of Well mlss�'-`z — — —- -- - -
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 at142 le
Disapproved for the following reasons:-- ------\J--- --____----__ _
---------— ---- -- =------- __ ----- ------ - - - --- --- - -- ---
---------- -----
date
Permit No.�--��--�'---1-�----------------
-------------------- Issued----------------------------------------------- -- - -
date
BOARD OF HEALTH
TOWN OF BARNSTABLE
(Certificate Of Compliance
THIS IS TO CERTIFY, That the Individual Well Constructed (>e), Altered ( ), or Repaired ( )
by----- - �- ! n �- ------------------------- --- ---- -- ----- -- -
Installek
at----- �'-7- ---C .r_ — — -- - —----- -- -- — -—
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. J =_--YY
—Dated-------_-
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL
SYSTEM WILL FUNCTION SATISFACTORY.
DATE------------------------------------------------ ---------- Inspector-------------------------------_ -- — -- -- -— -
41
No. Fee-�-
--= ------
BOARD OF HEALTH
TOWN OF BARNSTABLE
Zppfitat ion-for Melt Cootruct ion Permit
Application-is hereby made for a permit to ConstrucWk_
, Alter ( ), or Repair (. )an individual Well at: _
Location— Address V / Assessors Map and Parcel ,{/a
Owner Address
AA Lives ----`—�-----�c.<��4�----�i�' ___—<i�t'�Cs�•tip /fICI
Installer — Driller _ — — l Address
Type of Building
Dwelling--------
Other - Type of Building-----------------------_________ No. of
/ i Persons---------------
Type
of Well ----------!l-f -P ?s----_-_-
Purpose
of Well J>iirl1t ! _---------------------------------------
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.
Av ,� �
Signed--�=�---------=�-.�'-"=ire"--."�--�---�/l[�;�.v.,��- / date /�-
Application Approved -- - -- - -
-� -
date
Application Disapproved for the following reasons:------------------------------------------------------
----------------------------------------------------
date
Permit No. ILI--Q _—�',-L�-------- -- — Issued---- - ---- date -- — — --
BOARD OF HEALTH
TOWN OF BARNSTABLE
Certificate Of Compliance
THIS IS TO\CERTIFY, That the Individual Well Constructed (X), Altered ( ), or Repaired ( )
b ----_-_"_N\�_ n 1W.1 I ---------'''�_.�.�� �f/l ------------------------
q Installed
----------
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.
DATE- --- —__- ------ - -- ---- ---- Inspector----------------------------------------------- ---------
BOARD OF HEALTH
TOWN OF_, BARNSTABLE
Vern (ton5truttionPermit
No. ---i /9 __-r Fee---D_ -------
� ?�� -e.Permission is hereby granted
-- -----------
------`— - - - ��, ,
I J
to Construct Alter ( ), or Repair ( ) an Individual Well at:
No.
ia-----------------
-------- ---
Street
as shown on the application for a Well Construction Permit
%�_�_?_��__: ?_------------------- - --No.------------------------------------------------------------------ Dated-------------,- --- --
Board of Health
DATE - ---— ---- ---- -----—--------