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HomeMy WebLinkAbout0460 OLD POST ROAD (CT & MM) - Health (2) 160 ®Id Post Road A = 054� �60 r No. 0—aar-3 Fee— - BOARD OF HEALTH TOWN OF BARNSTABLE Applicat ion Ar Well Con5truct ion Permit Annli ation is a by ade r a e 1 o C9 stBuct (41), Alter ( ), or,_Repair.(_. an individual Well at: Location — Address Assessors Map an Parcel— Owner Address Installer — Driller Address Type of Building � Dwelling ----- --— ----- — Other - Type of Building-------------- - No. of Persons------------------ Type of Well e'C( — 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 We 1 Protectio Regulation — The undersigned further agrees not to place the well in operation un a icate i ' ce has been issued by the Board of Health. Signed — ---- -����—d� — all e Application A d By -P PP Approve _. � date Application Disapproved for the following rea s:— --------- - ------ - ---------- ---------------- -- --- ----- ----------------- date Permit No. — -- Issued--- -- -- - -------- -- date BOARD OF HEALTH TOWN OF BARNSTABLE Certificate Of Compliance THIS IS TO CERTIFY, That the Individual Well Constructed ( ), Altered ( ), or Repaired ( ) --------- ---— - ---- - ---------------- - — --- — y---�-- Installer --- ----- at- ----- -----—----- ------------- 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------- -- ----- —- --- �• No. (A)ao03 -oog Fee---- BOARD OF HEALTH TOWN OF BARNSTABLE 01pp[itation for Vell Con9tructionpermit A lication is he by ade or a e >Ao C stAict ("), Alter ( ), or Repair ( an individual Well at: ©� .� s� —— --- — Location —.Address --? Assessors Map and-Parcel — / Owner Address j Installer — Driller Address /( Type of Building Dwelling ----- -- —-- -- Other - Type of Building--_ -_______ No. of Persons------------------- T e of Well � �� -1—— 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 Protect' Regulation - The undersigned further agrees not to place the well in operation until a ficate �f' milli ce has been issued by the Board of Health. j ( Signed �1 Id Ate AV ' l/ 1 Application Approved By � ". — Jy���L� •U D �1 � , - / l l date Application Disapproved for the following rea s: -------------- -- - date Permit No. — — Issued--------- ------ - date i BOARD OF HEALTH r TOWN OF BARNSTABLE Certificate ®f Compriance THIS IS TO CERTIFY, That the Individual Well Constructed ( ), Altered ( ), or Repaired ( ) i i by------- ----------- - -------- ----- -- --- - -- -— ! Installer --------_-- ---- at- -— ---- ---—--_—__ -- — — ----- ------ 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 C Con5truction-Vermit �-- NO. � Fee- - ---- j Permission is hereby granted — !; to Construct (�), Air (/ , or-,Repair ( ) a dividu 1 Well at: as shown on�t/h'e�a , I*ttion for a Well Construction Permit No.-� ) /llJt v� _ Dated-- ) . D board of Health DATE I i • 1 i 1 I• I J. I I r• I r, I LO Ar le if 143. STC04E PATID •\ �. o I I 1 I �1 •. Jl.f.r---Ir-ti•. �ii Y -w��._ ,. lam.' Zf ! 'J +arc _ 1 1 _ III i' >,._�e�;=-jlrY.r• I"—�{--� 1 1 � �� ::pu,�� 1 I 4 _ I f Ir _ _ _ I to d NOT TO SCALE I �s 1