HomeMy WebLinkAboutUntitled 0—
BOARD OF HEALTH
TOWN OF BARNSTABL.E
Rppritation for Well Pr5truttion i3ermit
Application is hereby made for a permit to destruct an Individual Well at:
Location — Address Assessors Map and Parcel
Owner — —-- — — —Address
Installer — Driller Address
Type of Building
DwellingOther -- Type of Building---- ------ No. of Persons--
Type of Well—�r� T� -- Capacity—_- ---------- ___ _ _
Agreement:
The undersigned agrees to destruct the aforedescribed individual well in accordance with the provisions of The
Town of Barnstable Board of Health Private Well Protection Regulation.
Signed =�" =• - __ - �` -�� �/
Application Approved By—,,,,- ° -
- date
Application Digapproved for the following reasons:
date
Permit No.-- -1� —= --_ — Issued--------_ _ -
at
BOARD OF HEALTH
TOWN OF BARNSTABL.E
Certificate Of Compliance
THIS IS TO CERTIFY, That the Individual Well destructed bys
/ / Instal er
at .../ v . . . . ... `a. . . .yr . -,/. . . - u»s .-C. . . . . . . . . . . . . . . . . . . . . . . . . . .
has been destructed in accordance with the provisions f the T of Barnstable Board of Health as described in
the application for Well Destruction Permit No.. . . ,�-. A —
.at ... . / . . . f�l 1.UE.- . 1!�.�. . . . ..... .. .. . . .
�y*i �'
has been destructed in accordancee provisions of the Town of Barnstable Board of Health as described in the application
for Well Destruction Permit No. . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . ... .. . .. ... .. .. . . . .. . . . .. .
DATE-- ---- Inspector— -----
No.----------------- Fee--
BOARD OF HEALTH
TOWN OF BARNSTABLE
ApplicationArVell be5truction Permit
Application is here/by made for
a permit to destruct n Individual Well at:
= .���
Location — Address Assessors Map and Parcel
Owner —__-- Address M-----------
Installer — Driller Address
Type of Building
Dwelling
Other - Type of Building-------------- No. of Persons-----------------------------------
Type of Well 2 �, f --- ---- — Capacity
Agreement:
The undersigned agrees to destruct the aforedescribed individual well in accordance with the provisions of The
Town of Barnstable Board of Health Private Well Protection Regulation.
Signed —
d -date
Application Approved B — _ ° '--
PP y f / C date
Application Disapproved for the following reasons:-
f
- — -�— _-- --�f --
Permit No.—�' "� � Issued �D date
---
fidate y
BOARD OF HEALTH
_ TOWN OF .-BARNSTABLE
(Certificate Of (Compliance
THIS IS TO CERTIFY, That the Individual Well destructed by,
Installer
at . /aZ.d. . . . . . -9:` . . . C '"!: ., . .</. . . ... . . . . . . . . . . . . . . . . . . . . . . . . . .
has been destructed in accordance with the provisions of e TQwn of Barnstable Board of Health as described in
the application for Well Destruction Permit No.. . .t/ �"�a�"' . . . . . . . . .
wn
, . . . . .�. . . . . . . . . � Ct . . . . . . . . . . . . . . . . . . .
has been destructed in accordance with e the provisions of the Town of Barnstable Board of Health as described in the application
for Well Destruction Permit No. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . .. . . . . . . . . . . . . .. . . . .
DATE__----___-------------------------_._—____ Inspector
P -
BOARD OF HEALTH
TOWN OF BARNSTABLE
Vell Meetruction Permit b
--
No. Fee--------------
Permission is hereby granted--" !! /V �
to destruct an Individual Well at No. ,�- -------4D /L ! Y Y _ `�� ` —7
Street
as shown, on theapplipition for a Well Destruction Permit �
No.---�—�—__----G71--_.- - —------ - --— - - Dated — _�� �-,��c-'—J"— - -
Board of Health
DATE____ -
r