HomeMy WebLinkAbout0070 MAPLE STREET - Health 70
021 002
F-71
^.; TOWN OF BARNSTABLE
V- � 7'l�
LUCATIONL . /.Ofe S4-ee-4 SEWAGE # 7+ RO
VILLAGE�),OSD rpS-1a Ale ASSESSOR'S MAP & LOT/--'D-Gb?/-
INSTALLER'S NAME & PHONE NO.&O/0/GAIN �nsQ Y �0 oo-
SEPTIC TANK CAPACITY /, �Qd QQA/-?
LEACHING FACILITY:(type) _ S ! Sl (size)1�,� y�
NO. OF BEDROOMS PRIVATE WELL R PUBLIC WATER
�UILDEROR OWNER
DATE PERMIT ISSUED: & /S
DATE COMPLIANCE ISSUED: —cl t/
VARIANCE GRANTED: Yes No�
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TOWN OF BARNSTABLE
L'Alnc)'N SEWAGE #
Niml.-AGE �L l/�l y ,l�.Pa ASSES OR'S MAP & LOT •
7oEAv�(� NAME&PHONE N '
SE_PnC TANK CAPACITY U
LEACHING FACIL=: (type) (size) U ` l
NO. OF BEDROOMS
BUILDER OR OWNER klatll
PERMITDATE:_ COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the 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 leaching facility) Feet
Furnished by
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No.- ------/_ --`� Fee—12 -------------
BOARD OF HEALTH
TOWN OF BARNSTABLE
Application jorlVell Coofrurtion ftmit
Application is hereby made for a permit to Construct ( ), Alter ( ), or�R pair ( an individual Well at:
l)------- -_-- -�'''1 ' - - -- "---'�` ---A ------------�_��0�1 DU2� ———— — — ------
— --- _— --- —
Location — Address ` L Assess6rs Map and Parcel
Owner Address
Installer — Driller ! Address
Type of Building
Dwelling---------------------------------------------------------
Other - Type of Building ------------ No. of Persons----------__________________________________
Type of Well------�
---------------------------
YP - - apacity--------------_------_
Purpose of Well - y'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 until a Certificate of Compliance has been issued by the Board of Health.
Signed a—J-4 4q — -- - 1 2 7 �j
date
Application Approved B - — -_- t_
date
Application Disapproved for the following reasons:--------- --_--___� �_—_
date �_---
Permit No. C1 q---'-------------_—-- --- -- Issued -- -
date
-------------------------- -------- - `i
BOARD OF HEALTH
TOWN OF BARNSTABLE
Certificate (Of. Compliance
THIS IS TO CERTIFY, That the Individual Well Constructed ( ), Altered ( ), or Repaired ( t)—
I_ �tT j L
Installer
at------ - Z d/Vi lT __`' t d�
has been installed in accordance with the provisions of the Town of Barnstable Board of Health Private Wel Prot ction
Regulation as described in the application for Well Construction Permit No. -- - Jam_-__--Dated__1___-34---
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL
SYSTEM WILL FUNCTION SATISFACTORY.
DATE---------------------------------------------------------------—------------------ Inspector------------------ -- - -- -- -—------------
N Fee---------1-.------------
BOARD OF HEALTH
TOWN OF BARNSTABLE "'.
zippYitat ion-*rMil con5tructionvermit
Application is hereby made for a permit to Construct ( ), Alter ( ), or Repair ( ')aindividual Well at:
ID------— — --- ---------- ---- —__ ___ — - --- — --- -- —-- -----
r Location — Address Assess6rs Map
and Parcel
t
4 ':l
4P !-� l tt,?! r-� 3 r�a„
—— — — — �= ---- ——�— — — —'�— —T- —z —— -—------—
Owner Address
Installer — Driller Address
Type of Building
Dwelling------------ ------------------------—----------------------
i
Other - Type of Building --------------------- No. of Persons--------------------------------------------------
1Alfi
1 Type of Well --- ------------------------------------------ Capacity---------------------------------------—-----------
----------------------
Purpose of Well-----fit-t` `_`" 0V -----------------------------------
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 Q
Application Approved By----
- —�--—— - ---
-- ---
l,. date
Application Dapprove�d for th
following reasons:-------------- ------------------------------____—__ __________
iz 11 z
--------= , ,A ,. !�— --�-- ------
y y r �r . Y; t C ✓t t r i ' /: .' `.! �` ''7dat`e+r
Permit -► _t f - L r + 1, .l i v�f ( l , Issuedf
vv FNo v t Zs' ii y date
BOARD OF HEALTH
TOWN OF BARNSTABLE
Certificate Of Compliante
THIS IS TO CERTIFY, That the Individual Well Constructed ( ), Altered ( ), or Repaired
!/V1—F-1_In A-r-
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. ----- -------- 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
VelI Congtruction err t -
r
No. ---------------------- Fee------=------------
Permission is hereby granted-------- `/ --_� /l�/�' ----------------------
to Construct X, Alter ( ), or Repair ( t) a�'n Individual Well at:
No. -------- —T �=------ Street -----------------—-----------------------------------------------— —
-------------------------------
as shown on the application for a Well Construction Permit cp
No.------------------------------------------------------------------------------------------ Dated-------------------�'-�= -` -
-----------------_-------�=�---------------------------------------------------------
U Board of Health
DATE-------------------------------------------------------------------------------------
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