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BOARD OF HEALTH
TOWN OF BARNSTABLE
zippIication-*rIvell congtructiouvermit
Application is hereby made for a permit to Construct ( ), A er ( ), or Repair )an individual Well at:
-------c0�r- � ------ ------ -Q. oss v_ - -----------------------------
Location — Address Assessors Map,and Parcel
Ow er Address
u� et - --------- .01 -------11°AYl_1 ----�
Installer — Driller 4d ress �a q6�
Type of Building d
Dwelling-1-KI,_tJ � '--1- ---------------------
Other - Type of Building -------------------- No. of Persons----------------------------------------------------
Typeof Well- �ei � --------------------------- Capacity-----------------------------------------------------------------------
Purpose of Well-_Qi� � ° '�C�----------------------------------
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 -- s --------------- --------vlk.
97
- --
Application Approved By-- - �-------- - -- ---------— ----------------
date
Application Disapproved for the following reasons:-------—-----------------------------------------------------------------------------------------------
--------------------------------------------------------------------------------------------------------------------------------------------------------------
date
PermitNo. --- — ��-�' -— -- Issued------------------------------------------------------------------------------
date
BOARD OF HEALTH
TOWN OF BARNSTABLE
(C ertif icate ®f (Compliance
THIS IS TO CpERTIFY, That the Individual Well Constructed (may; Altered ( ), or Repaired ( )
bY---------- -----------------------------------------------------------------------------------------------------------------------------------
Installer
at--------------- --o-----ylktun-------------------------------------------------------------------------------------
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--------------------------------------------------------------------------
� — — ��.�Yy9_ _ ... a- �.1 ()/�V' -,.�-�--fir►:. .. 1 "'- �'a. ..
i
No,W_ --_L_ !_-__��tT- °, � _-. d� Fee----- - ---�''-..-_-- -
u. BOARD OF HEALTH v`
.. TOWN OF BA,RNySTABLE
Application-*rVe[Y Congtrutt ion Permit
C( Application is hereby made for a permit to Construct ( ) Ater ( ), or Re air )an individual Well at:
Location — Address j Assessors Map and Parcel
Owner Address
Installer — Driller Address
Buil
ing
-- -
II Type of Dwellings t F4_ ?� -------------------
j Other - Type of Building--------- ------------------- No. of Persons----- --------------------------------------------------
----- -
Type of Well Capacity------------------------------------------------------- --
Purpose of Well-_OLOM1-197_ -----------------------------------
Agreement: j
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 - �, --
ate
Application Approved B --
�_ date
Application Disapproved for the following reasons:------------------------- ---------------------------------------------------------------
---------------------------------------------- ------- ------ ---------------------
date
j
PermitNo. --- p�, - Issued------------------------------------------------- ----------------------
"' — — date
'I BOARD OF HEALTH
f TOWN OF BARNSTABLE
THIS• IS TO CERTIFY; That the Individual Well Constructed (�, Altered ( ), or Repaired ( )
® -------------------------------------------------------------------------------------------------------------------- ------
Installer
L -- -----------------------------------------
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---------------------------------------------------------------------------
�i�: S.Sar•.c.r�-a,.k..n-c�c• .W..��..fi._i..�� h�'+!e.��.�+..-4,a..yr...-_ � :..�..-.. �:-: - �_�. �.. -� - sa�,9��r�+r .:v¢•su�5;:�+s�-' _ - ..
BOARD OF HEALTH,
i
TOWN OF BARN-STABLE
�eCC�•�on�truct ion hermit
No. Fee------ -5- -----
--------- -------------------------
Permission is hereby granted----�- - ��--- --------------------------------------
to Construct (�-41 Alter. ( ), or Repair ( ) an Individual Well at:
No. - --- ' ' - -�'' — - ' ------------------------------------------------- ---------------
----- ----------
Street
as shown on the application for a Well Construction Permit
No.- - - -------------- -—- Dated ^►�
---- ---=.-------a�---' ------------------=------- -----
-------------------------- _
I
k ---------
ard of Health
DATE--— - --------------- - -- --
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