HomeMy WebLinkAbout0069 LISA LANE - Health 69 LI SA LN E%T, W. BARNSTABLE E `
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No. 4210 1/3 BLU
F-ESSELTE
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Town of Barnstable Health Inspector
' • of THE r� Office Hours
Reglllatory Services 8:30—9:30
Thomas F. Geiler,Director 1:00—2:00
snxivsrns .
MAsS.
1639• Public Health Division
`0�
ArE p � Thomas McKean,Director
200 Main Street,Hyannis,MA 02601
Office: 508-862-4644 Fax: 508-790-63C
AMNESTY PROGRAM APPLICANT- SEPTIC QUESTIONNAIRE
1. General Information: Size of Property:
Address: l0 / elf/ Map Parcel d//'11)dS�
Name: /IV Mwrnr Phone #:
2a. How many bedrooms exist at your property now?
2b. Are you planning to add any bedrooms? Af If yes, how many? �
2c. How many bedrooms total are proposed at this property (including the amnesty unit)?
2d. Please include a copy of the floor plans for the entire property - showing the existing
rooms in the home plus the proposed amnesty apartment and/or addition. Please label .
each room clearly on the plans.
3. Is the dwelling connected to public sewer? YES or NO
If the dwelling is connected to putzllc sewer,skip question"s,#4 through#9'below.;
4. Location of dwelling is INSIDE or OUTSIDE a Zone of Contribution to public supply wells? �
5. Is the dwelling connected to an ONSITE WELL or to PUBLIC WATER?;
6. Is a disposal works construction permit on file? ;`YES or NO
6a. If yes, how many bedrooms were approved according to this permit? Bedrooms.
? } Q)
7. Were any building permits obtained for construction of additional bedrooms? '
YES -or NO
8. Is there an engineered septic system plan on file at the Health Division? YES for NO
9. Has the septic system been inspected by a DEP certified inspector within the last two years? YES or NO
-----Y--------------------------------------------------------=--------------- ----
ID
�J v r -- FOR OFFICE USE ONLY ,
(D RheRipvi
� k cpaiaThe Public Heasion has no objection to bedrooms at this-property.
Special Conditions: - `'fir-a1\4A
Signed: Date:
O;/health/wpfiles/amnestyapp
TOWN OF BARN ABLE Iq
LOCATION SEWAGE#
VILLAGE. �LAU,—{r i"f A SESSOR'S MAP&LOTII'L1-obs
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY r4L.
LEACHING FACILITY: (type) 1 k l=/LTZA57?)-►Z4 (size)
NO.OF BEDROOMS c�
BUILDER OR OWNERS1Jt
PERMIT DATE: 9=�,l�-C?,S� COMPLIANCE DATE: e C;F/', �5
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leas fac' ' Feet
Furnished by
40 '
' 0 �--
I � „
(ne s ` R
1..
No..
f�s'rFr�s.... ..C.�.........
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
Applirativit for Dhi-V tial Wnrk,i Towitrnrtinn antit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
.
A Location-:\ddress or Lot No.
.... . ';ic 1_7-----•-•-••------------•---------- -•-"•----------------••-----•--•--•------'•---.................................................
0 r P Address
------
Installer Address
Type of Building Size Lot---- t
{—t Dwelling—No. of Bedrooms__________________ _____________________Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building -----------------1.......... No. of persons--.-_-----_------_..___.-._. Showers ( ) — Cafeteria ( )
dOther fixtures ---•-•-----------•-----------------•---•---------------•--------•----•---•------------- ---------------•-------------------------•---------•---------
W Design Flow...........................` .......gallons per person per day. Total daily flow--------- .................,......gallons.
WSeptic Tank—Liquid capacity------------gallons Length---------------- Width--------------- Diameter.--------------- Depth-_-_--______-..-
x Disposal Trench--No. -.___----/......... Width.._./a--------- Total Length...... Total leaching area-__-44<a_._.._sq. ft.
Seepage Pit No________--
,,,_Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( Dosing tank ( )
Percolation Test Results Performed b C/�P'r._ ��.�� � :✓_ 'e- Date_ __-.9 ___._._.....
a . Y —
Test Pit No. 1_L._.2----minutes per inch Depth of Test Pit._._-/�_.--__-_ Depth to ground water........................
(4 Test Pit No. 2................minutes per inch Depth of Test Pit_................. Depth to ground water........................
P4 ..--•••••------------ ----•------•........ --•-------------.......--- .......•- ..........................................................................
0 Description of Soil.,----._. �---l�fl1,S%Q9!>�......�flSjl�!�___
U '•••-•-•...............'•-------••-•-----•-•••--••--•---------------•--'•••-•••-•••----•-•---•••----•--•-------•--------•---------......-------••---------------••-•---•----------'••--•......-'---•--•-
w
.......................................... ---------------------------------------------------------------------------- --------------------------------------------------------------------------------
M. 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 TIT.L.E 5 of the State Environmental Code—The undersigned further agrees not to place the
system in operation until a Certificate of Compliance s b n is by e b and ealth. _
Signed .......... - - _... - G--Z1el
Dace
Application.Approved By 7
Date
Application.Disapproved for the ollowing reasons- ----------------_ .................................--....... .._...... ................_.....
-.-...--- ----------------------------------------------_............_---- ------------------------------------------- ---------- --------------------_..._..-------------------- --------....----------.-..--------------
�j _ Dare
Permit No. --------------- Issued -----------..-..�- g
Dace
No F
THE COMMONWEALTH OF MASSACHUSETTS V
BOARD OF HEALTH
TOWN OF BARNSTABLE
Appliratinn for Bi_t-iVi1sa1.1Vnr1w C> oustrurtion Frrutit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
............. ................., _-rT' la!xk'_ /
..............................
Locat/io�n-Add-ess or Lot No.
Al Owner
Address.
Installer Address
U Type of Building Size Lot__-_I
a " Dwelling— No. of Bedrooms".`,-----------_--•---------------------------Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building -----\------------------.... No. of persons-_-__------_---_..-__-..--.. Showers ( ) — Cafeteria ( )
Other fixtures . ---------------------•--•----:.__---------•-----•------------
W Design Flow...........................5_'�"~__' _gallons per person per day. Total daily flow........AI. .........................gallons.
WSeptic Tank—Liquid capacity------------gallons Length---------------- Width---------------- Diameter---------.------ Depth..............
x Disposal Trench—No. ----------/........ Width.....L0 Total Length
------ Total leaching area..._ _4.-----sq. ft.
Seepage Pit No--------------------- iameter---:.-'------------- Depth below inlet.................... Total leaching area..................sq. ft.
_z Other Distribution box Dosing tank ( )
aPercolation Test Results Performed by.. P=-- _-. ��L !v:>$--w�•� - !0 /1 - �'_�� � ----•------. Date....----•-•• -• ---•------
Test Pit No. 1._ __ -__-minutes per inch Depth of Test Pit.---- ------ Depth to ground water....
_._"'''___._____..
(S. Test Pit No. 2................minutes per inch Depth of Test Pit"_.,......_.._...... Depth to ground water........................
.............=-=-----------------------------------------------D ..........................................................................•------------------
------------------
Description of Soil_..._ -------- -------------------------------------- ----------------------•------
w.. S
w r - r
--------------- --------------------------------------------------------------------------------------------- --------- ----------------•------•.....-----------------------••--•-•-----•-•-•--•-----... -
U Nature of Repairs or Alterations—Anse e rl when applicable..............::...............................................................................
............................................................... •----•-• ..................................... .+
W'-,- _
Agreemenr. -- _ \ ;
The undersigned-agrees to.install the aforedescribed Individual Sewage Disposal System in accordance with ,
the provisions of TITLE %% the.State Environmental Code—The undersigned further agrees not to place the
system in operation until a Certificate of Compliance has beeh issue0by the board of-health.
-------------
f
k Signed - .... ...... ......D'3/..
Application,Approved By . ^'
._................................_...... ........ Dace
Application Disapproved far the following reasons: - � ----- ---------------------------------------------*. ..... -
----------------- -------....._---------------------------------------'--.._--------------------------------------------)----
^ Dare '
Permit No. '" �.. .......... � Issued --------------- .F-...
� Dare �
THE COMMONWEA^LTH OF MASSACHUSETTS
f
BOARD OF HEALTH
TOWN OF' BARNSTABLE
a, Ter#Y: tctt#e of Tomplianre
THIS IS'TO CERTIFY-That the Individual Sewag Disposal System constructed ( ."j<or Repaired
-.. ..... ................................y------.........................-----------.-------------
--
has been installed in accordance with the provisions of TITLE 5 of The State nvlronmental Code as described in
the application for Disposal Works Construction Permit No. ..1, '.-.1=/. .. _.- dated ............._.....«�,.."._-... ..._
- " 5 f
THE ISSUANCE OF THIS CERTIFICATE�SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE `' -- `'�' l A.----...... Ins ect6 .. �/ G ' ' 'i/ „/z'G'�2'�
-^-----__---_.___. „--,-------- --- ---.__.-_ ---- -- ----- -�_
THE COMMONWEALTH OF MASSACHUSETTS '
-\\ BOARD OF HEALTH
gg TOWN OF BARNSTABLE
No.---l. .....106 FEE.------
Btspoa ' nrk Tnno luli.bn rerntit
Permission is ereby granted...... o o...................... ,r
to Construct (V) or Repair ( ) an Individual Sewa e Dispos y tem
atNo.. �9 } � !�1--------------------•-------------.--------- ............................
Street 4r
as shown on the application for Disposal Works Constru tion Permi - ol��__ 1�- Dated....._-2_24-^_.,.1.-..-....
--- Board of Health
DATE _'_' �1. . ---.L_✓.................................
FORM 36508 HOBBS h WARREN.INC..PUBLISHERS
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ruOFFICIAL USE .
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k � Postage $ `J,S O
Certified Fee
C3 Return Receipt Fee Z 'X rk9 2008 "i M (Endorsement Required)
O
Restricted Delivery Fee
(Endorsement Required)
U
� r-9 Total Postage&Fees. $ _tSPCJ
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.A Sent To
Kevin S'* 0 r r 1
O Street,Apt No.;
o O Box No. lA
City State,ZIP+4
Q� Barn�izi��c ►�A oz���
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n A mailing receipt
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o Certified Mail is not available for any class of international mail.
a NO INSURANCE COVERAGE IS PROVIDED with Certified Mail. For
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c For an additional fee,a Return Receipt may be requested to provide proof of
delivery.To obtain Return Receipt service,please complete and attach a Return
Receipt(PS Form 3811)to the article and add applicable postage to cover the
fee.Endorse mailpiece"Return Receipt Requested".To receive a fee waiver for
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endorsement"Restricted Delivery".
a if a postmark on the Certified Mail receipt is desired,please present the arti-
cle at the post office for postmarking. If a postmark on the Certified Mail
receipt is not needed,detach and affix label with postage and mail.
IMPORTANT, Save this receipt and present it when making an inquiry.
PS Form 3800,August 2006(Reverse)PSN 7530-02-000-9047
4 to Complete items 1,2,and 3.Also complete A'Signature n
item 4 i;Restricted Delivery is desired. r ❑Agent
Print your name and address on the reverse ❑Addressee i
so that we can return the card to you.. B. Receive by(Printed Name)x, C. Date o
o Attach this card to the back of the mailpiece,
or on the front if space permits.
Article Addressed to: D. Is delivery address different from item 1? ❑Yes
If YES,enter delivery address below: ❑No
CPq Usa L W
V V Q 4 '9an�6 V I V 3. S ice Type
Certified Mail ❑ �Express Mail
N �/ /- ❑Registered ❑Return Receipt for Merchandise
O (P8 ❑Insured Mail ❑C.O.D.
4. Restricted Delivery?(Extra Fee) ❑Yes
2. Article Number ' , 7006 2150 0002 `1042 - 0286
((Transfer from service label)
PS Form 3811,February 2004 Domestic Return Receipt 1o2sss-o2-M-154o';I
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I UNITED STATES POSTAL SERVICE MA
fiefwQa'ii"+�M„A
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2t'JUL 2000S PT'j
• Sender: Please print your name, address, and ZIP+Z-1"is box • '""'
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-N�a�nlni s OA
bZ�ol
Certified Mail#7006 2150 0002 1042 0286
IKEfotia Town of Barnstable
x
Regulatory Services
IiARE+ISTA1li:E.
MAW Thomas F. Geiler,Director
tbgq. 1'b
Public Health Division
Thomas McKean,Director
200 Main Street,Hyannis, MA 02601
Office: 508-862-4644 Fax: 508-790-6304
July 9, 2008
Kevin S. Merritt
69 Lisa Lane
West Barnstable, Ma 02668
NOTICE TO ABATE VIOLATIONS OF 105 CMR 410.000 STATE SANITARY
CODE II—MINIMUM STANDARDS OF FITNESS FOR HUMAN HABITATION.
The property owned by* ou located at 69.Lisa Lane,West Barnstable,was inspected
in April of 200E by Robin Giangregorio,Zoning Officer for the Town of Barnstable. The
Town of Barnstable Health Division has been made aware of below violations on this
property. .
105 CMR 410.300 and 310 CMR 15.00: There were a total of six (6) bedrooms
observed in this dwelling. However, the existing septic system (permit # 95-1637) was
not designed for six (6) bedrooms. It was designed for three (3)bedrooms.
You are directed to correct the violations listed above within twenty-four (24) hours
of your receipt of this notice by ceasing and desisting the use of rooms within the
basement as bedrooms. You are also ordered to remove beds from said rooms.
You are ordered to remove (by pulling any permits if applicable); any three (3)
bedrooms from this home or garage by removing entrance doors and by opening all
door-way entrances to each room to minimum of five feet wide openings. This will
bring the total bedroom count down from (6) six to the appropriate (3) three as
designated by our records. You must either complete the above alterations to the
bedrooms or up grade the current septic system to represent the current number of
bedrooms. Due to the fact you are not within the Zone of Contribution to public
water supply wells you are eligible for this second option. This will entitle you to be
able to keep the current number of bedrooms. This must be done with proper
permits and engineered plans and be completed within sixty (60) days of your
receipt of this letter if you choose this option.
QAOrder letters\Housing violaticns\Rental ordinance\69 lisa In.doc
You may request a hearing before the Board of Health if written petition requesting same
is received within ten(10) days after the date the order is served.
Non-compliance will result in a fine of $100.00 per violation. Each day's failure to
comply with an order shall constitute a separate violation.
Should you have any questions regarding the above violations, please contact the Town
Health Division and ask to speak with the inspector who performed the inspection.
P=McKean,
RD OF HEALTH
T , O
Director of Public Health
Town of Barnstable
Cc: Timothy O'Connell, Health Inspector
Cc: Robin Giangregorio
i
Q:\Order letters\Housing violations\Rental ordinance\69 lisa ln.doc
E ENVIROTECH LABORATORIES, INC.
MA Cert. No.: M-MA 063
449 Rte. 130 . Sandwich, MA 02563
(508)888-6460 . 1-800-339-6460
FAX(508)888-6446
CLIENT: Aqua-Jet LOCATION: Lot 3
ADDRESS: 135 Rte. 130 69 Lisa Lane
Mashpee, MA 02649 W. Barnstable, MA
SAMPLE DATE: 7-14-95
COLLECTED BY: Ken/Aqua-Jet DATE RECEIVED: 7-14-95
TIME: 1:30FM LAB I.D. #: E7-195
JOB TYPE: New well SAMPLE I.D. #: 421
WELL SPECS.: 96'
RESULTS OF ANALYSIS:
Parameters Units Recommended Limit Result
Coliform bacteria/100ml (MF Method) 0 0
pH pH units 6.0-8.5 6.41
Conductance umhos/cm 500 136
Sodium mg/L 28.0 18.2
Nitrate-N mg/L 10.0 0.30
Iron mg/L 0.3 0.07
Manganese mg/L 0.05 0.004
Volatile Organics See report enclosed.
EPA 601/602 ug/L None detected.
Yes No WATER IS SUITABLE FOR DRINKIN URPOSES OR PARAMETERS TES ED
X%%
Date
Ro ald J. ari
Laboratoryfnirector
LT Less Than
GROUNDWATER
ANALYTICAL
EPA METHODS 601 and 602
Volatile Organics (GC/PID/ELCD)
Field ID: E7195 Lab ID: 11303-01
Project: Aqua Jet/69 Lisa Lane Batch ID: VG2-0660-W
Client: Enviroteah Sampled: 07-14-95
Cont/Prsv: 40mL VOA Vial/HCl Cool Received: 07-17-96
Matrix: Aqueous Analyzed: 07-19-96
PARAMETER CONCENTRATION REPORTING LIMIT
(ug/L) (ug/L)
Dichlorodifluoromethane BRL 5
Chloromethane BRL 5
Vinyl Chloride BRL 5 ,
Bromomethane BRL 5
Chloroethane BRL 5
Trichlorofluoromethane BRL I
l,l-Dichloroethene BRL 1
Methylene Chloride BRL 1
trans-1 2-Dichloroethene BRL 1
1,1-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-Chloroethyl Vinyl Ether BRL 5
cis-1,3-Dichloropropene BRL 1
Toluene I BRL 1
trans-1,3-Dichloropropene BRL 1
1,1,2-Trichloroethane BRL I
Tetrachloroethene BRL I
Dibromochloromethane BRL I
Chlorobenzene BRL 1
Ethylbenzene BRL I
meta-and Para-Xylene * BRL 1
ortho-Xylene * BRL I
Bromoform BRL i
1,1,212-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
a,a,a-Trifluorotoluene 30 31 102 q 87 - 113 %
1,2-Dichloroethane-d4 30 32 105 % 83 - 117 %
BRL a 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).
7-21-967:29 AM --------
----'-'
ASSESSORS MAP N0:
� � �,, '�-'.�-, PARCEL NO; 1
No. - ------ --- -- Fee----------------- --
BOARD OF HEALTH
TOWN Off' BARNSTABLE
Application-for Well CongtructionPermit
Application is here y made for a permit to Construct (Alter ( ), or Repair ( )p individual Well at:
Location — Address Assessors Map and Parcel
- E v;''' -12�------------ -- -------------------------------
Owner Address
Q --------�E-T --------------------------------------- -------4es_'oo ---------------------
Installer — Driller Address
Type of Building
Dwelling------�`�� — �----------------------------------------
Other - Type of Building---------------------------------- No. of
P01774ES'G- —
Type of Well— —- -- --— -- - 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 Cej,.-tificate .of Compliance has been issued by the Board of Health.
Signed
date
Application Approved — �r`�------------- — r �� ??�
date
Application Disapproved for the following reasons:—_ __________—__—___________—_-__-____________—__—__--_____
date
7--—
Permit No. --- —`� =--- --- Issued--------------------- ----- --------
- - ----------
date
BOARD OF HEALTH
TOWN OF BARNSTABLE
(Certificate ®f (Compliance
THIS IS TO CERTIFY, That the Individual Well Constructed f""T,, Altered ( ), or Repaired ( )
b -—-- -------=— ----------------------------------------------------------------------------------------------—-------
— —-
y- -- -
- Installer
---- -a ?� = �i's' -- '`J�`--------------------------
at-- �-
----------------------------
has been installed in accordance with the provisions of the Town of Barnstable Board o Health Private Well Protection ;
�w� /
Regulation as described in the application for Well Construction Permit No. -----=---------- ____ ated�----�6--`-�-
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL
SYSTEM WILL FUNCTION SATISFACTORY.
DATE-------------------—- —-- —---------- — — - Inspector----------------------------------------------------------------------
J^c.:,,�}3rY .YK. ktir.'" w�P`li T -.�1KT-Y•'1a`; -.�v^t r+^ H'°"'S^t"'�r .riY;.f'2� + H- s ,'+ ' . i.
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:,
40
No. -- - Fee
T.- a. BOARD OF HEALTH r'
TOWN- OF BARNSTABLE�"
Applicat ion-for Melt Con0ruct ion Permit
Ap lication is hereby made for a permit to Construct (`�), Alter ( ), or Repair ( ) individual Well at:
-------v--7---3 ----- - - =- --- -Ll/- - �1 '00 ---- -----------------------
Location - Address Assessors Map and Parcel
Owner Address
-------�c- ?�_ _ -- --- -- - - -`� 5 �7/, -G 'ems- -
' Installer - Driller Address
Type of Building
Dwelling — -------------------------------------
Other - Type of Building ------------- No. of Persons------------!----------------------—------_-------
T eofWell- --AO/r1ES/^l -C= -- - - - --- -----
YP -- -- — - 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 ertificate .of Compliance has been issued`by the Board of Health
Signed. ?—-//- 5
date
Application Approved -- [! tip--_---- --- — — �
C�iC••�=„���iUj �date
Application Disapproved for the following reasons------------------------- -------------------------------------------------
---------------------------- --- ----------------------------------------—----------------------------------------------
dat _
Permit No. -- -- _ Issued--- — -`--- —- -- -
date
f.ate-® .. �e��_��-.mae,a��..=,�s-a+...�+.�....r.s.,..�.....s:�®�.w.,s�.�.a.w�.c.a•m�.n..rawr�...w-ss ter.-s.....�.arp
~ BOARD OF HEALTH
TOWN OF BARNSTABLE
C ertif irate Of Compliance
THIS IS TO CERTIFY, That the Individual Well Constructed (V,4 Altered ( ), or Repaired ( )
--------y by- - ------4)L'f}- - - - --— -- -- - - --- —--
Installer
at— --- a ----- --------
Itip----------------;-----�.
has been installed in accordance with the provisions of the Town of Barnstable Booaarrddtoi kee�a'lth Private Well Protecti/on
Regulation as described in the application for Well Construction Permit NoP�"_=_-!-"�-- ed__7r �P--- ..,7
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL
SYSTEM WILL FUNCTION SATISFACTORY.
DATEInspector------------------------------------ ---------------------------------
BOARD OF HEALTH
TOWN OF BARNSTABLE
Melt Construct ion Permit
No. 11�?$ !l---_— Fee-
Permission is hereby granted- ____— vr9 ,J __
to Construct (_y' Alter ( ), or Repair ( ) an Individual Well at:
No, ------------------------------------------------------------------------
Street
as shown Oil the pli z4on fo Well Construction Permit
No. - ` — — - Dated - -
1
---
Board of Health
DATE
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' \ The installer is to insure that
�- 5 '- of suitable mate ri,a•3-;.is below
th-e proposed system;._.
L_ •;, ��.� ram.. �
Use 4: infiltrators with,4 ' of
10, � stone on sides 'and 1' of stone
14 v , for a base. A1'19 2 6To11,
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