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Home My WebLink About0053 MEADOW LANE - Health 53 Meadow Lane W. Barnstable 4 A 133 006 '. No. 4210 1/3 BLU 4 V 1Q% ` I .y CERTIFICATE OF ANALYSIS Page` Barnstable County Health Laboratory Report Prepared For: Report Dated: 6/10/2003 Order Number: G0319909 Eric Hesse ir��P -� � 53 Meadow Lane PARCEL ; 0 6 West Barnstable, MA 02668 LOT Laboratory ID#: 0319909-01 Description: Water-Drinking Water Sample#: 19909 Sampling Location: 53 Meadow Lane,West Barnstable Collected 5/27/2003 Collected by: Eric M.Hesse Received 5/27/2003 Routine ITEM RESULT UNITS MCL Method# Tested LAB: IC Lab Nitrates <0.1 mg/L 10 EPA 300.0 5/28/2003 LAB: Metals Copper 0.1 mg/L 1.3 SM 311113 6/3/2003 Iron 0.1 mg/L 0.3 SM 3111B 6/3/2003 Sodium 32 mg/L 20 SM 3111B 6/3/2003 LAB: Microbiology Total Coliform Absent P/A Absent 309 5/27/2003 LAB: Physical Chemistry Conductance 110 umohs/cm EPA 120.1 5/27/2003 pH 7.8 pH-units EPA 150.1 5/27/2003 Note: Sodium levels are higher than average. Those on low sodium diet may wish to contact physician. Approved By: (Lab Director) ��:,. �. :{9... _ -i+'y> ✓ire.. 1 - . \ l 7.' 1 I Superior Court House, PO.Box 427, Barnstable, MA 02630 Ph: 508-375-6605 t� /r TOWN OF BARNSTABLE LOCATION c d L,L, SEWAGE # VILLAG ASSESSOR'S MAP & LOT/'ZS,- INSTALLER'S NAME & PHONE NO. o�f ia-pz� SEPTIC TANK CAPACITY / S�e pT I L -ham.K- LEACHING FACILITY:(type),i,-�1-1 TA,ri- (size) gley NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNER �►�u�Nstl DATE PERMIT ISSUED: �►/� �"' � � DATE COMPLIANCE ISSUED: '°"�,� ��' a •" f�' VARIANCE GRANTED: Yes No �� Tiolv /J I No 135 3-3 60(7o THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Appliratiou for Dhi-p 3al Wnrkai Towitrurtiuu rrrmit Application is hereby made for a Permit to Coristruct ( ) or Repair (Ilq an Individual Sewage Disposal System at _ .............. d.... ..---•----------------------------•------- -•-- ---------- .._...• ... ocattot - \ddr ss or Lot No. Installer Address UType of BuildingExpansion Attic Size Lot............................S ( )q. feet Dwelling— No. of Bedrooms.___. p ( ) Garbage Grinder Other—Type of Building _-________________________ No. of persons--------------------------- Showers ( ) — Cafeteria ( ) Otherfixtures --------------------------- ----------------- ----------------•.........--------------- ---------------- W Design Flow........ . ,•�1� gallons per person per day. Total daily flow.....q ........................gallons. WSeptic Tank�Liquid acitJ� gallons Length-----14 ----- Widt k?._-_------ Diameter---------------- Depth................ x Disposal Trench Width.....4------------ Total Length---34d...... Total leaching area....................sq. ft. Seepage Pit No...................... Diameter-------------------- Depth below inlet.....................Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date........................................ 14 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 Test Pit.................... Depth to ground water........................ 9 •---••-••-----••---------- ---------------------•-•------•-----••----•--•-•-•--••---•----•-•.....-•--•••.....--••••----------•--•-••-•....._......--•-------- 0 Description of Soil....................................................................................................................................................................... w ------------------------------------------------------------------------------------------------------------------------------------ U Nature of Repairs or Alterations—Answer when applicable.__ ti5?K1.C(_.__. :G� ___ c.__71 .................... 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 Comp been issu oard of- ealth: Signed .�... ------ .. .�V�.".�� g :...... Date Application Approved By ----- ---- -------- --- -------- ------- -- -- -- -------- - -------- ----------------- ----------------------------------- .................Dare....... ....... ..... Application Disapproved for the following reasons- ------------------------------------------------------ ...... - --- .................................. ........................ ........... .. .. ....- .... ...................................-......---------------....-................... �............... Date.................. PermitNo. . �............ . .------ ----------------- Issued f - ......................... ate No... ....... ✓'� THE COMMONWEALTH OF MASSACHUSETTS r BOARD OF HEALTH TOWN OF BARNSTABLE Appliratiun fur Biipuiittl Worth Tomitrurtiun Prrmit Application is hereby made for a Permit to Construct ( ) or Repair ()<5-an Individual Sewage Disposal System at: � _ a�c _.... ......... ::..•-------•-- ° ..............................--------•------...------••----...--•---------.........-----...--'•-- ............ -� c a =-C' -tom o tionhAdd...s or Lot No.P- \( M\. ..l Owner Address Installer Address UType of Building Size Lot............................Sq. feet t-. Dwelling—No. of Bedrooms--__Y�___.______•-__•----------------_-Expansion Attic ( ) Garbage Grinder ( ) Other—Type of Building ____________________________ No. of persons-_--_-.__.__•-_-____---.-._. Showers ( ) — Cafeteria ( ) dOther fixtures ----------------_------ -----------....•----------...----------------------...--------..........------. W Design Flow. . ......................gallons per person per day. Total daily flow----- WSeptic Tank�Liquid capacitvj,�(19)gallons Length......14)..._ Width_ ---------- Diameter._.--..-_-__.._ Depth................ x Disposal Trench Width._............... Total Length.-- ...... Total leaching area....................sq. ft. 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-.--_.--_-.__-__.---._-. 44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ 9 --------------------------------------------------------------------------------••-•--------•'-•'-"......................................................... 0 Description of Soil......................................................................................................................................................................... x V .....••••••--•-••---••••••-•••••-••-•••....-----•••----•---•--•••----•----••-••-••••••------••-•---••--•-•-•-•----------------•............--••••-------•-----•-•-•-•---•--•----••-'••--•---'-'-•--•--•- W U Nature of Repairs or Alterations—Answer when applicable..= .!5�7 6 (.._/15X/22_„ram:,,7. y!k.•- .............. t , - -%f, 'iA v ---------------- -••------- 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 Complia c has been issued by-the board of Health. Signed ................. ..-.... -- ------�... --�---�---- 1 � ..............._......... DareApplication Approved By .....P�4, � f%. ---- --- .. .............. V Date Application Disapproved for the following reasons. ....................................................................... ....... . .........-------------------...... (� r Permit No. ------.... -- -- --------------------- Issued ..... -.--.--�-- G� ------------...gate / ate ——(jl --———————————`—————————.——.————————————— —————_——————————————--—— —————— THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF'BARNSTABLE lbPrtifirate of Tomplinure THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( ) by --------------------------------------- -----/----A.P-- („t_1c-�/�_ all rr .... J�1.a _.....0 . _� ' �jst has been installed in accordance with the provisions of TITLE�of The St to Endronmental Code as described in the application for Disposal Works Construction Permit No. ... ..'�.. .... dated __.----------------__--_-_------.._.. T BE CONS TREA A A GUARANTEE THAT THE THE ISSUANCE OF THIS CERTIFICATE SHALL NOS GU SYSTEM WILL FUNCTION SATISFACTORY. DATE ' / 4�------------- ----- ---- Inspector -��*�'i..._7o�7... _ -----------`2 _. _- J-` ----------------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH � 3 TOWN OF BARNSTABLE No...... ......./... FEE..__._...0....... Mipcoal Workii Tunutrudiurt "remit Permission is hereby granted.......... 'f _'_._ ., _�- ____ z' ;� ............... to Construct ( ) or Repair ( ) an Individual Sewage Disposal System atNo............................................ ._..Z_..��- c e-��----z::�-------;l��r//---/mil- ------------------------•---------•--••-•--••-- Stree as shown on the application for Disposal Works Construction ermit tNo_�,.f--_J.,,�____ ated._&:m............................ . . ✓ �B....oar f Health -,•• DATE_ � .._..-••-•-•-•-•---•- I FORM 36508 HOBBS 6 WARREN,INC.,PUBLISHERS /71 NoC7� ........... THE COMMONWEALTH OF MASSACHUSETTS BOARD-OF HEALTH . ........,.....B-Ci.M.,47 ..J ............................. Appliration for Dhyaaal Works Tonstr,urtion ramit Application is hereby made for a Permit to Construct or Repair (A) an Individual Sewage Disposal Systeth at- .... (-w-e- ............... ..............................I....................................................*............... cation-Address Lot N L.Mt Wnmn.............................. .......W. bt...................... Mdress ....0AR .. .........C ........................................... a CD_M.M,n�+. ��.4.�� _0 Installer Address Type of Building Size Lot............................Sq. feet Dwelling No. of Bedrooms............................................Expansion Attic Garbage Grinder CL4 Other—Type of Building ............................ No. of persons............................ Showers Cafeteria P4Other fixtures ........................................................................................ Design Flow............................................gallons per person per day. Total daily flow............................................gallons. 9 Septic Tank—Liquid capacity............gallons Length................ Width................ Diameter---------------- Depth.........---.... W Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. 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................minutes per inch Depth of Test Pit---.--............._ Depth to ground water........................ (Z4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water...-................---. 9 .............4.............................. ............................................................................................... 0 Description of Soil................ ........................................................................................... W ....................................................................................................................................................................................................... ........................................................................................................................................................................................................ U Nature of Repairs or Alterations—Answer when applicable...... .....P..i.I .................................................. ......................................................................................................................................................................................................... Agreement: The undersigned agrees to install the aforedescribeid Individual Sewage Disposal System in accordance with the provisions of TL I Ti U 5 of the State Sanitary Code—The undersigned further agrees not to place the system' in operation until a Certificate of Compliance has 1keen issued by the board of health. 19 S, .. ".A_? ...... Application Approved By..-...- Sig ..... i...... .. .. ..U1.W_ ...... D ..................... Date Application Disapproved for the following reasons:............................. .............................................................I....... ....................................................................................................................................................................................................... Date Permit No-------------------------------------.................... Issued------i/_IV—" ................................................ Date N0................_....... Fss............._..... .... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH 1.� .........OF..... . ,f:1�1) Lrf .. '.............................. Appliration for Uiipusal Worka Tonstrurtion randt Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at• ) _ .... .. ..r ti , ....# t e�......................................... ............._.._....-•---•-- •--•------- ••---•. •......._..............-----.. I Location-Address _ or Lot No 4 C;=•....-1.q•a,.�J F_ 1 ------•---•---------- ....................f .-----•��_�l..... ....: •••-f r t�..=-..................... Owner f ,- Address aI ! . ) .. -f: ---11-•-•- --•-•--•-•_ �---l•�•c,�-.1 t_/..% �..................•--._....................... Installer ° Address Type of Building Size Lot............................Sq. feet �. Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) Other—T e of Building No, of persons............................ Showers — Cafeteria W Other fixtures d -•-------------• 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.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No....:.:.............. Diameter..................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed byyR.........................................••----------••-•----............ Date........................................ a Test Pit No. l....__`�": .:..minutes per inch Depth of Test Pit.................... Depth to ground water......................... Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ 0 Description of Soil..................:_:`_._r 3C.# ` • - - -- --- - - - - x c, w UNature of Repairs or Alterations—Answer when applicable...___�_ �_._�_�.�?___.. f% ' Agreement: -a The undersigned,agrees to install :the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TIT1 , 5 of the State.Sanitary 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. ign d' f-- �- �.`....................... ......................... nk}! =� ................� . _. � __ _> 7_ Application Approved By r` "............ ......................... ..__.... ...------..........------•-- Date Application Disapproved for the following reasons---------------•----...-------••----•---------------------------•----•------•------..........._--•------•--•-•-- r ...........................•----------•-••---•----•--------------•--------.....---...---•-------•---....------'=--•----......_._.....-----•--------------------•---------------••••---•-------••-•-•••-f Date l Permit No.............................................. ......... Issued....................................................... Date THE COMMONWEALTH`OF MASSACHUSETTS 5' BOARD OF ?HEALTH ........ .........................OF�..: `.:.. (1:. ?. ........ }.......... Tatif ira r of Tontphaurr : THIS I TO CERTIFY, That the Individual Sewage_Disposal System constructed ( ) or Repaired (,X) b .............................� r< %.. <� .---..__ ----_--*.._aa : .................................................... staller "f t l C 'C �I-J ,F' /. _. 1 �n..7.-�_f__�__ . ___ `�r _ ir_ l wJ __f_t/l has been.-installed in accordance with the provisions of T }�r 5�0^,The �tate Sanitary Co as esc e m the application for Disposal Works Construction Permit �'o...tl`"-.._.__GP__..!`�U Q" dated_...._!_..."..... ............ }4 THE ISSUANCE OF THIS CERTIFICATE""S,HALL NOT BE CONS4'RIIED AS A GUARANTEE THAT THE WILL FUNCTION SATISFACTORY. 4- DATE � -- SYSTEM WI �� -••-ll..`. .... .............................................. Inspector....•- ......... ................ THE COMMONWEALTH OF MASSACHUSETTS BOARD_.OF HEALTH �— k. - ............ ..........OF, I_: ...............----................................. /`%, L� No._._:._...C<--2•�• FEE........................ Miposal 10orkiiion t trt un �rnti Permission is hereby granted...... .. .. ........................................................' �'_r...: "l .............•---.........---••••-....... to Construct ,( ) ..or Re air 1(N an Individual Sewage Disposal System at No..-�2.... '.............%� f;,f J 1- f.,.1 ...... •-t.f/f .. Street / /` A Q as shown on the application for Disposal Works Construction Per it)No............. - I} t ._ r H � DATE-------- --� ---`-� &..............•-•--.........••-------- Board of ealth FORM 1255 HOBBS & WARREN. INC., PUBLISHERS No................ Fps........ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ............................ ............OF................-..........-----.........--------............ ...._...-.. ..._._......_. Apli iratiun for Dhipoiial urkii Tonutrurtiun rumit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at ..............•k-%3 �r�.-�o ��...... �s 12 / Location-Add r or Lot No-/'_ ......................_.... ...- ... ..... -------- .................. --..... a •---•...................•--•....? __Ownc_.:. .�!-1-v- .... 0'!i16(dlf'f .. /�Addrg�ss� lsl9jm _S .......... P Installer Address Type of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms............ ............................Expansion Attic ( ) Garbage Grinder ( ) Other—Type of Building ____________________________ 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................ Disposal Trench—No_____________________ Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No----------_--------- Diameter.................... Depth below inlet.................... Total leaching area.__...............sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date........................................ a 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 Test Pit.................... Depth to ground water........................ P+' ................................ • ------- ••-------------------- •••--------------------- •-------------------------------------------- _..... _--••--••--....._-- 0 Description of Soil......................................................................................----------------•-----------------------•--------•-------•---------..........-- V --------------- •------------------------------- ___----------------- •---------------- _-------------------------------------- •----------------------------- •--------------------------- _------------ W U Nature of Repairs or Alterations—Answer when applicable--------i.'& ' ; _J �e_ ]We................................... .. . --•-------•----•-----------••-----------------------------------------------•--------••-••••-- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITIE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has be • su by the b rd eal Signed.......... ........................ -•------------------•-•-•-- ------........-•--........ Date ApplicationApproved By.................................................................................................. ........................................ Date Application Disapproved for the following reasons:................................................-............................................................... .............................................._.......................................................................................................................................................... Date PermitNo.......................................................... Issued-....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS r_ BOARD OF HEALTH ......... .............. P• ._ t. ........._......................................:.. At ertifiratr of Tompliana IS S TO Jhat the Individual Sewage Disposal System constructed (4) or Repaired ( ) by ... '--- -------------------------------------------------------------------------------------------------------------------•---------•_.._. Installer at--••---•---•-•--------------•---------------.._..---•-----------•-•-•---•--•---------- has been installed in accordance with the provisions of "' 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit N ....... dated--... �- 7_ _.._._.__._ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE................................................................................ Inspector................................................................................... 4, nc� No.................. .. r Fps.......: ............_ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH/ OF............................................ .......................:....:...:...:. ............ ".....---------._..............--- Applirtt#ion for Digpoottl Works Tongtrurtion Prrutit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at ................__..0... ........................ ...-------••------------••------•--•-- ----------.........------...- -_.. Location-Add or Lot No. _ ......................----•-�- "' f up f'................... ............,4 .__ ` I►(.yi+ '.•_..- "-°�""-�---- W •--------•--------------•-- Ow l l} a_-!�y-... .�lY.. sa! .... ..� 1� «M Installer� Address Type of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms........... .............................Expansion Attic ( ) Garbage Grinder ( ) a'4 Other—T e of Building No. of ersons____________________________ Showers YP g ---------------------------- P ( )--- Cafeteria ( ) Otherfixtures -------------------------------------------------------•-••--•---•••-••---•••••••••••---••-••--••-•••••••--•-•-•••. ....-_-•_. W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. 04 W Septic Tank—Liquid capacity............gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No_____________________ Width.................... Total Length.................... Total leaching area....................sq. ft. 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........................ 44 Test Pit No. 2................minutes per inch Depth of Test Pit............-....... Depth to ground water......................... a -••••-•-••••-•--------------•-•=-••--•-•••--•-•-•-•••-•••...-•-•--•-•....._..••-•-•-------•--_------......................................................... 0 Description of Soil....................................................................................................-................................................................... x V ---------------- ------ ------------- .......----------- _------------------------------------ •--------- ---------------- --------------------------------------- .....----------------- •------ ----•-------------------------------------------------•---•--•-•-•---------•-•--•-•--------------------------• r i.......................... ..._..--•-••-•--.....---_.... U Nature of Repairs or Alterations—Answer when applicable.....__t !-' ►fJ--- P.,v 4 e V 40e..__._•__________________ -------------•--------------------------....-----------------------------------------------•-_-•••••--•--••-...-••••••--•••-•---••••-••-•••-••••--•-----------------.-.-----------------.._............. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITIE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has be • su by the bard hea Signed . .: �0 ` ------------------•. ........ Date ApplicationApproved By.............................................................=.................................... --•••-••-•••-•---••-•------••• Date Application Disapproved for the following reasons-----------------•--------------------------------------------------------------•--------------------------_...-- ....................•-••......_...-------......_..--•----••-•............-••--•••.....-•-•••----•--•--•-•.-...-•-•-•••-•---••-•--••••-•-••-••••--•-•••---------•---••••••-•----•-•-••••••--•-••••-•----•- Date >:.. Permit No......................................................... Issued-....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF : HEALTH .....f..`" ..............OF..... �..-�'�..�. -....................................................... �rr#ifirtttr of f�ottt�rlittnrr IS IS TO TI . That the Individual Sewage Disposal System constructed ( '') or Repaired ( ) by ---------- ---------•-•-•---•--••••---------------------------------------•---....__...._•---- . .....-----••-•-------•-•-- Installer at has been installed in accordance with the provisions of 5 of The State Sanitary Code as descrlbe m the application for Disposal Works Construction Permit N / +tIry r �t,} `*�dated ¢G� +--••--••• THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE-THAT AT THE SYSTEM WILL FUNCTION SATISFACTORY. : " DATE p s r. Ins ector El v � r : ,y,q.:J.y "J.I^ .i„" ) �h. N�X :� R k-. "!�`r`r�yj.fi St xk t • :>aw r. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ........ ................OF...... �. ..... No..__.._. ` `.... FEE.. ....:........ Big o I: rko no ion rrMit Permission is hereby ranted•. to Construct ( ) or Rea an Ind>vidual Sewa Dap yst -s at No.. lY la O4; dr ................ _/ j t�'" *" . •••-• --- ..... Street as shown on the application for Disposal Works Construction Perm• V- 4 t _. .............. / ---J . •••- Board of Health DATE---_/126"" _•=----------------•••-•-••-•---•--•-••--- FORM 1255 HOBBS & WARREN, INC.. PUBLISHERS q� Fee- W No.-------------------- �------�� BOARD OF HEALTH TOWN OF BARNSTABLE Applicat ion-*r Vell Con5truct ion Permit Application is hereby made for a permit to Construct ( ), Alter ( ), or Repair ( )an individual Well at: ----------- ----------------- - ------ cation — Address Assessors Map and Parcel Owner ! Address Installer Driller Address Type of B wellin - -------------------------------------------------- Other - Type of Building No. of Persons-------------------------____—__—_______ Type of Well 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 gertificate .of Compliance has been issued by the Board of Health. 1-7 Signed �,Q�� /date/ j Application Approved By 4 �c� -- — ___ — �'!14 _ date Application Disapproved for the following reasons: — —-- — - ----— — -----------------—— ---_--------- > J —4 date Permit No. Issued--- �- 6 —------— date BOARD OF HEALTH TOWN OF BARNSTABLE Certificate Of (Compliance THIS IS TO CERT FY, That the Individual Well Constructed ( ), Altered (s'), or Repaired ( ) - -------------------------------------- 33 � � /�I"I''nstaller ------------------------------- --------------- -- has been installed in accordance with the provisions of the Town of Barnstable Board/oof alth P 'v e WeQll Proptection Regulation as described in the application for Well Construction Permit No. '!�"_ � =6_ l`"9 4 THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORY. DATE----- --- —- Inspector--------- - —- No.-------------------- Fee--/---`'-�------�''--�� BOARD OF_HEALTH j y TOWN OF BARNSTABLE App Citation or ell �Conaruation erne f ? Application'is hereby made for a permit to. Consttct Alter ( ), or Repair ( )an individual Well at: ahon Address Assessors Ivibp and Parcel r : f . Owner — .` Address — - - Installer Driller - Add f ress Type of B ! Dwelling — -- - ------------------------ Y Other - Type.of Building-=--------— --- No..of Persons---- ------- Type of Well———--=-- -- = - Capacity-- — - - --——--- - -- — Purpose of Well------�__ «� -- --y - •,,. ' . 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 noteto place the well in operation until'a Certificateof Compliance has beenrissued by. the Board-'of Health. Signed — —--- — - —_ /_—�—�-- date Application Approved By i date f Application Disapproved for the following reasons: Y ----— -- - _ ----- - --------------------- - — r date. Permit No:_�''—L�� . -- Issued.---- O Z�-�-�------- 1, , it date +r?�R�4iiwTiM�e+i9�9o�rleS�iii:eiYrrc'fla�hii1144!i.?Q�+r'RidEaTi'lii2b AiV8�9sbwi4sTi66Ri4SpGRS!1►'Aimee"x0Y16!Pi'R`+2i'9iTi4i�i!yab�b!�?!itilhiSi4iYliTilliitoTr9�rYtlfagb!ilafiRiiSi+ti-'!b!i!i!r!irr 'J BOARD OF HEALTH TOWN OF BARNSTABLE ' ' 'f C ertif irate. f compunte i, THIS IS TO CERT FY,LThat the Individual.Well Constructed ( ), Altered.(-'), or Repaired ( ) I 11 Installer — --- has been.installed in accordance with the provisions of the Town of Barnstable Boa d of alth P 'v^te Well Protection /,�� Q p Q Regulation as described in -the application for Well Construction Permit No. '- '`` ' Fed.—? THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORY. , DATE----- -+ ..Inspector-- ----- -♦>i1!�+ir6lirk011TiT0lYlriirilK►P/i�iYi.RATG�ilhililitiPiMb�iiY4i�lb'ii��4iQibd9AlilS+6BiTiWK4i0.raTdRlliTS9lilily,L+Jy�y!kYy'elNw+Y.!aRbl�Wdayey�i f!i41R�MYi�i�i�irir4o� BOARD OF HEALTH TOWN OF BARNSTAB.LE Well �Cootrurt ion Permit r . No. ! U Fee Permission is hereby granted ---____--__-_ to Construct ( ), Alter ( ), or Repair ( ) an Individual Well at: i --- ----------- Street as shown o ,the plication fgA51r'a�11 Construction Permit, i / — --- Dated— ------------------------------------------ Board of Health 'C DATE—L— I