HomeMy WebLinkAboutMiscellaneous - 550 BOXFORD STREET 3/31/2015 TOWN OF NORTH ANDOVER,
Office oJ'(."0MM1JN1TY DEVELOPMENTAND SERVICES
HEALTH DI "AEA T EN .
1600 OSG'00E STREET;I; liI'TE 2035
NORTH ANDOVER, MAS AC_"C UST-11 01845
Susan Y. Sawyer,REHYRS 978.688.9540- Phone
Public Health Director 978.68U476 F AX
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Well and/ter Em Application
(PIease print) / DATE:
LOCATION to Drill Well or install a pump: 60',, r090 f '
Licensed Well Contractor Name and Company Name: 11A(It' (° ° gr +�d" CC,• P
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Contact Phone Numbers:
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Address: (,4 f ft l/*1 4�, 7%rt1 g I? rf`�1 ✓�►v'w v ^
Contact Phone Numbers: l4 -7 G+ 3 1 — cl-5- .3
WELLS(to be compleped V at time of p un..p test)
Type of well:
Use: V o('1.e s- 1„C—
r-
Diameter of well: Size of Casing:
Depth of bedrock: Depth of casing into bedrock:
Seal been tested? Yes( ) No( ) Date of test:
Depth of well: Water-bearing rock:
Depth of water: Delivers: GPM for:
(how long)
Drawdown: feet after pumping: hours at: G
:ALDate of Completion: %G/
Signature o ell Contractor
PUMPS(To be filled in before installation)
Name&size of Pump: Type:
Size of Tank: Pump delivers: GPM
Pipe used in well: Cast Iron_ Galvanized Plastic
Sleeve used to protect pipe? Yes No Type of well seal:
Date:
Signature of Pump Installer
Date water analysis report submitted to Health Department:
Plumbing Wiring Inspector Health Department Representative
S:\Hea1MPermit Applications\Well Application.doc