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Home My WebLink About0270 COMMUNICATION WAY - Health (3) ry i 270 Communications Way Sewer Acct # 7580 Barnstable o 1 F A = 314-041 —OOF Bld'gl No. 4:2=---� BOARD OF HEALTH TOWN OF BARNSTABLE 0ppiicat ion-*rVeil Congtructionpermit Application is hereby made for a permit to Construct ( ), Alter ( _ or R pair ( an ' divi ual Well at: :54to Qar-VVr*r-er ._______________-_______________________________________________________________ __________ 1 _---- ' ' Location — Address Assessors Map and Parcel Mall, M.4-44-,?-eu, erv'7- i__H ,vivLS -- '`}nvnot S 6PF'(c� � ie/� --- ------------------------ --------------------- — ---------------------------- ---------------- Owner Address 'TT4')vTt,C We-11------------------------------------------------------------------------------------- ------------ Installer — Driller Address Type of Building f tr Dwellingr i L� Other - Type of Building No.No. of Persons----------------------------- l� Type of Well---,,y— p 14 W<_ - — Capacity---------- - -- -------------------------- Purpose of Well---- '-4T-___(_°-42-------------------- 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 Compliant has been issued by the Board of Health. r � Signed date Application Approved Bye 4`4 `.J - -� �------- ---- ---- -------------- `J date Application Disapproved for the following reasons:------—------------------------—-------------------------------------------—----- ---------------------------------- ----------------------------------------------------------------------------------—------------------ q date Permit Now--1_- =-�� --------------------------- Issued — -— � � � '�r� — ate-------------- date BOARD OF HEALTH TOWN OF BARNSTABLE C ertif irate ®f Comphanre THIS IS TO CERTIFY, That the Individual Well Constructed ( ), Altered ( ), or Repaired ( ) ----------------------------- Installer — �,ml�t , --------------------------------------—---------------------------------- at has been installed in accordance with the provisions of the Town of instable Board of Health Private Well Protection Regulation as described in the application for Well Construction Permit No. Ab_-Jf_____Dated THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORY. DATE---------- -- - Inspector—- - lt \------------------—--- --—-------- r ew.+ ::.a ., a , ..,...a- .6 _ "'3'N v"'s°'�: =.�'-" .sJ"�'' ^. �.k'::a�..Wan4r ia•v'�w.... r rA-.vrn w+,ems.-�Mk`M'h -k+sa'Gl�wE�.e.Fa.s� �r No. 4�2=---Lt----- �,-';.. Fee- BOARD-OF HEALT Tp111/-N OF BARNSTABLE ZIP' licat ion-for Well Congtruct ion 3ermit Application is hereby made for a permit to Construct ( ), Alter ( ) or Repar ( an indivi ual Well at: YV 4t* t*N Location — Address Assessors Map and Parcel KYA. Nov/S_- - - - f-'4Niv/ �- aFF(cr- OK-tel,. -- i Owner Address 1-4-ry 77'c C Gv e l! .-Vry 1/I►u L.I C 7 9 - -2 7 o C� �u N i crc�r.r,� GJ Installer Driller Address Buili Type ofDwelling--- -----— -- ---- ------ Other Type of Building G4't-S(�e ct��-�? No.. of Persons---- t y t' �/ W< !� e C Z� Type of Well- -- - - Capacity--------- ��{ ,' - - - ---- ht Purpose of Well----�r✓►--- _v4J r°-AJ - j. f j Agreement: n 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 untilia Certificate .of Complianc has been issued by'the Board of Health. Signed ---- ----- - .2 /-y- - date ApplicationApproved By - ----------- --- -= ---------- ti date _ t' Alpplicatiori.Disapproved for the following reasons:---------------------------- —----------------------------------- ------------------ j r t ------------ -- ---— - -=-- ------------------------------------------------------------------------" ------- date Permit NoV- ------------- Issued - -- - - -` —------ date mac- aews -a�a�vaens;.se aowree xaastic+ara•40=XM#mC=s ma-CAMGeem-t eaw OEM. BOARD OF HEALTH TOWN OF BARNSTABLE C ertif irate ®f Compliance = f 'i THIS IS TO CERTIFY, That the Individual Well Constructed ( ), Altered ( ), or Repaired ( ) ` Installer----- ----- - by- - "'� - ------------—- --- - - ----- .- has been installed in accordance with the provisions of the Town OfWmstable Board of Health Priva e Wlell_Erotection Regulation as described in the application for Well Construction Permit No. Dated a THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT-THE WELL SYSTEM WILL FUNCTION SATISFACTORY. DATE Inspector --------------------- -° ----- • i BOARD OF HEALTH t TOWN OF BARNSTABLE Vrll Comtruttioni3ermit =--- -- Fee -' Permission is hereby granted-=-= -- --- ------------------ ----- ----- IT'S., . to Construct ( ), Alter ( ), or Repair ( ) an Individual Well at: No. --- - -- - ----------- ----- -------- -------- ---------- ------ --- Street —. I as shown on the application for a Well Construction Permit j No.- - -- ----- ------ -- -- - . Dated--- - d-_ --4-------------------------------- ------------------------ -------------------------------- ._ aoard of Health j DATE r Date: 7L�'y/ TOXIC AND HAZARDOUS MATERIALS REGISTRATION FORM NAMEOFBUSINESS: ei4n,�;ki- BUSINESS LOCATION: '7® MAILING ADDRESS: 6q vy e- Mail To: TELEPHONE NUMBER: Board of Health. � 7 l--� � '� � Town of Barnstable CONTACT PERSON: ®�.�sc P.O. Box 534 EMERGENCY CONTACT TELEPHONE NUMBER: Hyannis, MA 02601 TYPEOFBUSINESS: 11-14=b Does your firm store any of the toxic or hazardous materials listed below, either for sale or for you own use? YES NO X This form must be returned to the Board of Health regardless of a yes or no answer. Use the enclosed envelope for your convenience. If you answered YES above, please indicate if the materials are stored at a site other than your mailing address: ADDRESS: TELEPHONE: LIST OF TOXIC AND HAZARDOUS MATERIALS The Board of Health has determined that the following products exhibit toxic or hazardous character- istics and must be registered regardless of volume. Please estimate the quantity beside the product that you store. NOTE: LIST IN TOTAL LIQUID VOLUME OR POUNDS. Quantity Quantity Antifreeze(for gasoline or coolant systems) Drain cleaners NEW USED Cesspool cleaners Automatic transmission fluid Disinfectants Engine and radiator flushes Road Salt (Halite) Hydraulic fluid (including brake fluid) Refrigerants Motor oils Pesticides NEW USED (insecticides, herbicides, rodenticides) Gasoline, Jet Fuel Photochemicals (Fixers) Diesel fuel, kerosene, #2 heating oil NEW USED Other petroleum products: grease, Photochemicals (Developer) lubricants, gear oil NEW USED Degreasers for engines and metal Printing ink Degreasers for driveways & garages Wood preservatives (creosote) Battery acid (electrolyte) Swimming pool chlorine Rustproofers Lye or caustic soda Car wash detergents Jewelry cleaners Car waxes and polishes Leather dyes Asphalt & roofing tar Fertilizers Paints, varnishes, stains, dyes PCB's Lacquer thinners Other chlorinated hydrocarbons,._ . , NEW USED (inc. carbon tetrachloride) Paint & varnish removers, deglossers Any other products with "poison" labels Paint brush cleaners (including chloroform, formaldehyde, Floor & furniture strippers hydrochloric acid, other acids) Metal polishes Laundry soil & stain removers Other products not listed which you feel (including bleach) may be toxic or hazardous (please list): Spot removers & cleaning fluids (dry cleaners) Other cleaning solvents Bug and tar removers WHITE COPY-HEALTH DEPARTMENT/CANARY COPY-BUSINESS