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No.- - --- - ---- Fee-�-�-----------
' BOARD OF HEALTH
TOWN OF BARNSTABLE
App[icat ion-*rVeil Con5tructionA3ermit
Application is hereby made for a permit to Construct Alter ( ), or Repair ( )an individual Well at:
8a ,-M� STD&
---------- --- ---------------- - - � ------------------
--------------------------------------------------------
Location — Address Assessorr s MaInd Parcel
q �Q
Owner Address
n � a�aQ3 ��u��s / o�G 5.3
- -- --- - - - - - -�- ----------
Installer Driller Address
Type of Building
Dwellin &O 6litG1Qi�vGj Osv S�TC
g — — - -- -------------
Other - Type of Building -------- No. of Persons-------------------------------------------
/r`Sa1c �o
Typeof Well-------------------T-------------------------- Capacity-----------------------------------------------
Purpose of Well----- 7& -----------
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 rtificate f Compliance has been issued by the Board of Health.
Signed -— - ---- - -- -- — c7 �G -- --- �—
® date —
Application Approved By ------- - - - -- - - -
date
Application Disapproved for the following rea s:-------------------------------------------------------------------
------------------ — - -- ----------------------------------------- /d.
tiPermit No. --— - — —--— Issuedte
BOARD OF HEALTH
TOWN OF BARNSTABLE
Certificate ®f Compliance
THI'S IS TO CERTIFY, That the Individual Well Constructed ( ), Altered ( ), or Repaired ( )
-------------------------
Installer Q �
t -- — — — — -------------O-r M
at-_-__- -_ - _--
has been installed in accordance with the provisions of the Town of Barnstable Boar Healt ate Well Protection
Regulation as described in the application for Well Construction Permit No. -- - -------------------
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL
SYSTEM WILL FUNCTION SATISFACTORY.
-------------------DATE Inspector-------
----
------------------------
----
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.� - --- Fee---------------------
BOARD OF HEALTH`��. =
f TOWN OF -BARNS`.TABLE
zipplicat ion Ar Well Congtruct ion Permit i
Application is hereby made for a permit to Construct (✓), Alter( ), or{Repair/( )an individual Well at:
-- �------------`-EMT
------------------------------- ---------- —r - -y-- — - �
Location — Address y� Assesrsors amMa and
Parcel
c;// 0! It.�/tiSl/,iL�/N 4B' Cyi Aoz //"vS
Owner. — Address
Ss-�o�-�� -1 __ �cc.:' ------------------------- d-- �„ 63 - —//le L�,ei,L 5 -:• ='may a�65�
ti
Installer — Driller r Address x
{ Type of Building
Dwelling �-
�0 c�jGl ow---
-- — -------
Other - Type of Building-------------------------------- No. of Persons--------------------------- —---------
Type of Well— -* -`S�/:---- - -------- - Capacit
Purpose of Well - - - - 7& — - —-
--
Agreement. r '
The undersigned,agrees to install the.aforedescribed individual well in accordance.with the.provisions of The j
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 +
i
Application Approved By �. ----- = --,�: -
Application Disa , roved for the following rdate
ea ns:----------
PP PP g
s
— — --— — - - - -------—-----
—— — —— — — —^ '——----
� I date -------- ;I.
Issued—_ —` ---—Permit No. ------- ,
_
arc i
BOARD OF HEALTH
TOWN 'OF xBA�RNSTABLE
certificate Of Compliance
THIS IS TO CERTIFY, That the Individual.Well.Constructed ( ), Altered ( ), or Repaired
-------------------- -- - -------------- ---------------------------------
by-, -a"r ---- f ---- - --------
01
/I l / !i Ell,�d_�O� t Installer—� -- f --
has been installed in accordance with the provisions of the.Town of Barnstable Bo/ar/d Healt ate Well Protection
Regulation as described in the application for Well Construction Permit No - �- -- ated----------------------
i
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL
SYSTEM WILL FUNCTION SATISFACTORY. 1
rDATE- --- ---—-- = -— ----- Inspector--------------------------------------------------------------
BOARD OF HEALTH
TOWN OF BARNSTABLE .
-` Well Contructionpermit
No. -------- --- Fee-- -----r;
Permission is ereby`granted- � f--`� - --- �� fr
to Construct ( ), Al er ( ).o R air (� ) an I ividu 1 Well at:
`.'
No. --— - — - -- — �y —in
- �f I -'-------------— -- — - -—-- -------------- -- ------
/ — Stree
as shown on the app icatiqn/fo.r-a Well Construction Permit
No. --� / — - ---- o—----- — - . Dated------ - -— n
'---- - - -
^4" _ ` =-
--- L - —! ----— -
- Board of Health
DATE