HomeMy WebLinkAbout3118 MAIN ST./RTE 6A(BARN.) - Health 3118 Main Street
Barnstable
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BOARD OF HEALTH
TOWN OF BARNSTABLE
311 q�r App[ication,�orVeli �ConaructionVermit
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App�licaation is hereby made for a permit to Construct (P")', Alter ( ), or Rep ' ( )an ind'vi al Well at:
; 1 _(per e --
r Location — Address s Map and Parcel
Owner Address
---------------------------------------------------------------------------
Installer — Driller Address
Type of Building '
Dwelling- st/1J1 ii9�--_____---
Other - Type of Building =--_—__—_______ No. of Persons--- -.----.._--___
Type of Well &e. --= ---- Capacity—___ - - ——---- ---
Purpose of Well-- !, , r0`_`-✓__—__
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.
Signe � _ -- _—___ _--
_ _ — —� � to �
Application Approved By m _ -__ _
at
19
Application Disapproved for the following reasons:
date
Permit No. ® ® _— Issued---- - - ___ __
date
BOARD OF HEALTH
TOWN OF BARNSTABLE
Certifirate ®f Compliance
THIS IS TO CERTIFY, That the Individual Well Constructed (Altered ( ), or Repaired ( )
l Installer
at__ l �' � � �� � 61�
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------__- -------__----
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-
BOARD OF HEALTH
a
TOWN.. OF BARNSTABLE
5
,�) 01pplicat ion,�torWell Con0ructionPermit
,�.j
311f 4 �r >1 ;
Ap lication is hereby made for a permit to Construct (Alter ( ), or Replair ( )an individual Well at:
Location — Address - — ssessors Map and Parcel —
--��/.,__-------------- —_ �— _�__--------------------Owner Address
Address
------------ -------- ------------------------
Installer — Driller
Type of Building
Dwelling AOther -- Type of Building --- No. of Persons--- _--_-.--_-_-------______
Type of Well tl Ca acit
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 a Certificate.of Compliance has been issued by the Board of Health.
Signe _� �_--A— -- —
n � to
Application Approved By.,
date
Application Disapproved for the following reasons: --_ -
— date
Permit No. Issued--- _-----
date
r
BOARD OF HEALTH
TOWN OF BARNSTABLE
y= Certificate Of Compliance
THIS IS TO CERTIFY, That the Individual Well,Constructed Altered ( ), or Repaired ( )
Y - ---- ` —__---- -—_-- -- -—
/ C./ Installer-
at (�� (,()SST Jlse
-----------------------------
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-- -- --- - - --------------
BOARD OF HEALTH
TOWN OF BARNSTABLE
Well Congtruct ion Permitze
No. Fee-- ------
Permission is hereby granted �� '�
J
to Con jtte, or Repair ( ) an1Individual Well at:
Street
as shoe�the� apfpiicatior� for a/Well Construction Permit _
No.- . Dated --- -
lard of Health
DATE
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