HomeMy WebLinkAbout0008 HARRIS MEADOW LANE - Health ,' II 1
��� �J`I
tiatr.S ,v
JL
No. Fee--
10-
BOARD OAALTH ,� -
TOWN OF BARNSTABLE , J
2pplicationArlVell Congtructionpermit
Application is hereby made for a permit to Construct ( /off, Alter ( ), or Repair ( )an individual Well at:
Location - Address Assessors Map and Parcel
--------------------- -------
Owner Address
- - ------------------ --------- ------------------- --------------- -
Installer - Driller Address
Type of Building
Dwelling
Other - Type of Building--------------- - No. of Persons--------------------
C -1 Capacity— �� ,�
Type of Well -�----- P Y------------------- — - -
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 Health Private Well Protection Regulation — The undersigned further agrees not to
place the well in operation until e e li ce has been issued by the Board of Health.
Signed
A/W
Application Approved By
date _D d e
Application Disapproved for the following reasons:
------------ — - --- ------------------ ------ --- -- -
date
/ ---- Issued -1 - -- --- — ------
Permit NO. date
BOARD OF HEALTH
TOWN OF BARNSTABLE
Certificate Of Compliance
THIS IS TO CERTIFY, That the Individual Well Constructed ( ), Altered ( ), or Repaired ( )
by-------- -------— - —--- - ----- -- --- — - -- - ------- ----- --
Installer
at- ----- -- ---------- - --- - ------ --- ------
has been installed in accordance with the provisions of the Town of Barnstable Board of Health P`` 'vate Well Protection
Regulation as described in the application for Well Construction Permit No� — �8aEed-- -------
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL
SYSTEM WILL FUNCTION SATISFACTORY.
DATE-------------------—-- ---- Inspector-- - — - - -- --——- ---
' _ � Q ' Fee- �- = --_----r No. u
I BOARD OF HEALTH ��
i
TOWN OF BARNSTABLE
Zipplicat ion Ar Veil Con5tructionVomit
•4_fiT
1.
G
Application is hereby.,made for a permit to Construct (Alter ( ), or Repair ( )an individual Well at:
Location —.,Address Assessors Map and Parcel
Owner Address
------ ----{----- - --_--- ------- - -
Installer l— Driller _ Address
Type of Building
Dwelling_—_—--- -- — —-- —
Other'- Type of Building-- ------- - - No. of Persons------------------------
-�� Capacity
Type of Well
——=-- ---- — --- f� -- ---
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 Health Private Well Protection Regulation - The undersigned further agrees not to
jplace the well in operation until a-Ce Z ate •f C''o pli ,ce has been issued by the Board of Health.
/-1
/a a
Signed - — -- ----- ^� — — date ----
� ---
Application Approved By ��� �G 0 � --- — -- � -� i
7f / d/e
z
Application Disapproved for the following reasons: -------- —--- - ---
-------------- date
� --- ------ — ---- ------ -- .'
�D - -- -/ � `- -
Permit No.� {} — Issued— date
BOARD OF HEALTH
! TOWN OF BARNSTABLE
Certificate Of COMPhance
I ,
THIS IS TO CERTIFY, That the Individual Well Constructed ( ), Altered ( ), or Repaired ( )
k
by Installer
i
at
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 NoWAQO �7�a eed------------------
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
TOWN OF ,BARNSTABLE
Veil Cap5truct ion Permit
�o - � --�
W _� Fee---------------
Permission�i hereby granted A -- - -- -
to Construct
( N, Alter ), or Repair n
dual Well at f
Y,2P-1�S //!� r ) --, -------- --------
{ �I 7T' Street
as shown gn the application for a ell Construction Permit �o
•- / _C/ ------- --
P ti!i�� _ '/ CSC_.-----�---- Dated- � ---- ----------
No.-
y -----------
/� Board` f Health
'{ DATE —
i
aY ..r
THE FOLLOWING
IS/ARE THE BEST
IMAGES FROM POOR
QUALITY ORIGINALS)
\1 A\G, I
DATA
ttv 9 L ON l ✓�. j A ea cN SEWAGE # 9��
VILLAGE_ ASSESSOR'S MAP &LOT-2 7 f"
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY IZ o U
LEACHING FACILITY: (type) ��` (size)
NO. BEDROOMS
I 1 ..
i B JILDER OR OWNER �
PERMTTDATE: l COMPLIANCE DATE:
A
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by !:-:Z
s� , oh