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BOARD OF HEALTH
TOWN OF BARNSTABLE
Application for Well Con5truct ion permit
4plicat' n i hereby made,for a permit to Construct Alter or Repair ( )an individual Well at:
Location — Address Assessors Map and Parcel
--—-------------——----------------—----------——-—----- —-—-----------——--—----------
___;7 Owneri Address
....... .. -------------- -----------------------------------------------------------------------------------------------
-�n
Type of Building -lnPs;ta;1l'e, — 19ril1CjrT Address
Dwelling-------—----- --------
Other - Type of Building-----------—-------------------- No. of Persons-----------_---_---------------__—______
Type of Well
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 !�alh Private Well Protection Regulation — The undersigned further agrees not to
place the well in operation un a,-, certificate .of Cop,",'ia ce has; b�en issued by the Board of Health.
Signed 12
IVA--
date/
Application Approved By --—------—---
date
Application Disapproved for the following reasons: —-------------------—----------------------------—---------
------------ —----------—-------—---------—--------
date
/01116�1—
Permit No. Issued —---------
date
BOARD OF HEALTH
TOWN OF BARNSTABLE
(Certificate (Of Compliance
), or e air the vi6ual Well Constructed Alt red R p i,Ld THIS IS T0_,C IRY That
by------------/ lie- - - - --- - ---
at-------------- n 11 staller
k64 �G---ce—-----Dci-----------------------------------------------------------------------
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 10 ated
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL
SYSTEM WILL FUNCTION SATISFACTORY.
(7j 1
DATE------- Inspector —----------------------------
�..1.FSY�r.7"JZa`Y,'T+M�1�h'.1..-�` _ �I.._ t�S^�.� 4ti..il.t.�f 41��.. I��N�Lti-'ry� 1..-.r .. .�Yti i � '.^�Y: • �t f 1 ♦ .. � ., .,{.�'i ..Y , \
'7 --— Fee---------------------
BOARD OF HEALTH
TOWN' OF BARNSTABLE
M iicat ion ArVeif Contruction Permit
Appli at.on is hereb made for a permit to Construct�( ), Alter ( ), or Repair ( )an individual Welltat:
Location - Address Assessors Map and Parcel --
----—-------------—----------------—----—----—---—-----------------------—— -----------—---------------------------- -------------------—--------------------
Owner, Address
. ,� ---------------
Installer — Driller Address
I
Type of Buildings��d� „/ y
Dwelling.....
-- -
r
Other - Type of Building----------------------------------- No. of Persons--------------------------------
Type of Well—-----—- -- —- - ----— -- - Capacity -
Purpose of Well
Agreement:
The undersigned agrees to install then aforedescribed individual well in accordance with the provisions of The
Town of Barnstable'Board of Ph Private Well Protection Regulation — The undersigned further agrees not to
place the well in operation un T
Certificate .of lia ce has`b iMt&C4
the Board of Health.
Signed - — ---
date
Application Approved By ------ -- -- --- —- -— —--— --------------
date
Application Disapproved for the following reasons:—_—_____—______—___—____________—______—_—_________—__—___—______—_
-----------— -- - - --__-- --- — ------ - - ---------------—--------------------------— -----------------
date
- __-
Permit No. -- --r �----------------- Issued----- _` � ---------------------
date
.w�.m•n.�:�.o•ano�m..,�.-Q..��vn.�»ss�we.e�..-..v..�,.,
BOARD OF HEALTH
TOWN OF BARNSTABLE
(Certificate ®f (Compliance
THIS IS TO� IF,Y That the ividual Well Constructed ( ), Altered ), or Repa' 1
by------------- - �� -
— ---- -----
staller
at---------------------- 3 ��---�- _ —�� --,Q .-------- - - —--- - - — -
has been installed in accordance with the provisions of the Town of Barnstable Board of Health Private Well rro_te(,ion
Regulation as described in the application for Well Construction Permit Nord �'- ...
-Zated a ff, &I
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL
SYSTEM WILL FUNCTION SATISFACTORY.
at
DATE - r - - --- -- Inspector--------------------------------------——- --—
BOARD OF HEALTH
TOWN OF BARNSTABLE
Veil (Con!9truct ion Permit
,----- &__
FeePermission is hereby granted----------
to Construct ( ), A4a, ), or epair ) Individual W 1 af�t+:
NO. •.�a — (^-i_-- — —— ——--------------------------------------------------
Street
as shown on the applicationfor a Well Construction Permit /
No. -- -a'� �-- �'—--- ---- - Dated -/ L -- —
;` -------------- -
Board of Health
DATE —
T