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HomeMy WebLinkAboutMiscellaneous - 1030 FOREST STREET 4/30/2018 (2)w MAP # PARCEL # LOT # 3 STREET �Q�'._. _:_. _. _....._. �ONSTRUCTI_QN APP __....._. HAS PLAN REVIEW FEE .BEEN PAID? Y NO PLAN APPROVAL: DATE Iy 7 APP. BY DESIGNER: �f�5T�i9iUSl>� PLAN DATE. // Z 7� CONDITIONS WATER SUPPLY: TOWN WELL WELL PERMIT DRILLER AV&441vo WELL TESTS: COMMENTS: .... _.. _..... ..... . _._.__._.... CHEMICAL DA1 E APPRUVED.4 BACTERIA I DALE flPPRUVED �1 / BACTERIA II DAZE APPRUVEVcFZ�/ `r 1 FORM U APPROVAL: APPROVAL 1'U ISSUE YES NO DATE ISSUED Z `lam BY CONDITIONS: FINAL APPROVAL:. ALL PERMITS PAID NO WELL CONSTRUCTION APPROVAL NU SEPTIC SYSTEM CONSTRUCTION APPROVAL YES NO OTHER YES NU ANY VARIANCE NEEDED YES©© NO FINAL BOARD OF HEALTH APPROVAL: DATE•O_Z r BY: Ao 'w MAP # PARCEL # LOT # 3 STREET �Q�'._. _:_. _. _....._. �ONSTRUCTI_QN APP __....._. HAS PLAN REVIEW FEE .BEEN PAID? Y NO PLAN APPROVAL: DATE Iy 7 APP. BY DESIGNER: �f�5T�i9iUSl>� PLAN DATE. // Z 7� CONDITIONS WATER SUPPLY: TOWN WELL WELL PERMIT DRILLER AV&441vo WELL TESTS: COMMENTS: .... _.. _..... ..... . _._.__._.... CHEMICAL DA1 E APPRUVED.4 BACTERIA I DALE flPPRUVED �1 / BACTERIA II DAZE APPRUVEVcFZ�/ `r 1 FORM U APPROVAL: APPROVAL 1'U ISSUE YES NO DATE ISSUED Z `lam BY CONDITIONS: FINAL APPROVAL:. ALL PERMITS PAID NO WELL CONSTRUCTION APPROVAL NU SEPTIC SYSTEM CONSTRUCTION APPROVAL YES NO OTHER YES NU ANY VARIANCE NEEDED YES©© NO FINAL BOARD OF HEALTH APPROVAL: DATE•O_Z r BY: Ao a �EPTG�SaL�IM� NSI�4�.HT Q�l :.q X r•,.;i `t i � , r 'ti.,;.a> , '' . '.a= r #;. `: \.t" J -;ti - ii�c. '�2A SIS THE INSTALLER LICENSED? ` �� YES NO TYPE. OF CONSTRUCTION ? '_ NE NEE REPAIR' a ,. NEW CONSTRUCTION:`,... CERTIFIED PLOT PLAN ,REVIEW Y NO " ' 1 CONDITIONS OF., APPROVAL .. S NO (FROM FORM U) a ' ',ISSUANCE OF DWC PERMIT NO TrDWC PERMIT NO. % a ,INSTALLER: HEGIN INSPECTION ��'''0: ' EXCAVATION. INSPECTION: ;NEEDED: PASSED zr— HY .'-.- CONSTRUCTION INSPECTION: „ .::, NEEDED: AS BUILT PLAN SATISFACTORY: YESs� BACKFILL: DATE: BY APPROVAL. TO FINAL.GRADING APPROVAL: DATE `'�BY FINAL CONSTRUCTION APPROVAL: DATE:A/45-� 1 I /NV P/PE INTO r4NK INV PIPE OUT OF TANK /NV P/PL' INTO D. BOX r l /NV ENO OF PIPE Wd TEie LL EY,4 T/ON .4VE'2.46E STONE DEPT// .47 PeOBE 1 1 (/50) y = /50 - _ ........................... J X }.fir° DES/CSN aEI/.4T/ON .4T ......... (TOP OF 570NE) _ .............................ri EX/5T/NCS ELEYQT/ON qT ......... �CEQU/�E'ED F/LL = R FY.QT/ONS DESNGN .4.5 BUILT HS A211/ ' INV PIPE OUT OF AVOC ' /NV P/PE INTO r4NK INV PIPE OUT OF TANK /NV P/PL' INTO D. BOX INV PIPE OUT OF D. BOX l /NV ENO OF PIPE Wd TEie LL EY,4 T/ON .4VE'2.46E STONE DEPT// .47 PeOBE NOTE'. T///S PZ.4N /5 NOT .4 41,4eeWAITY OF T//E 5Y57EM BUT .4 YES/F/C.4T/ON OF Tf/E 4OC,4T/ON OF TWE EX/ST/NC STeUCTUk'E5. SUB—SU,2F.4CE �Oo4L SYSTEM FOR 5C.4LE: _ ;,` - ' DATE: - ' //4 XENO2Q ,4VE., W-41/E�'fl/L L, M<l. 199S 4:2SPH FPO 1 COLONIAL VILLAGE SOB 682 2397 S I OMAR I NEE P-01 m l arms 16 EAST MAIL[ STREET. P-4. BOX 1153, GLOUCpSTEA, MASS. TELEPHONZ8 (508) 281-0.22 FAX. i5C8; 283-3374 01Si31•i153 CERT! F i ICAY£ OF RNRLVS 15 COLONIAL VILLAGE DEVELOPMENT CORP 7010 SALEM STREET REPORT NO.: 9515W N AN06CR, MA 01W AUGUST 23, 1991 ORCTERI LOGICRL RNRlySIS -- Now well, 250 feet deep, located on Lot 3, Forest Str , N. Ar►daver, MA Sample taken tay Customer on August 21, 1995, SIR ; Total Coliform 8aCtWW CouW10i? mL _ . p 2sl : Analysis perforf and in *cCordance with Standard Methods for the Examination of Water 3 wastewater, 17th Edition, 1989_ R=Arksi The baaerW4" gra ly of this 8,arinpie was ftwrrp to meet the r UireEllents at Mass. bepartmont of Envirorxnentei P1010CUm'S 310 CMR 22 -OD, "Drinkin; Water Ae Mations" for human aonsumpt*. yYf �3� - .10ke)MM tfx JWds tab Direct or CC: North Andover Board of Health - -- - MASS CERTiFiEL) LA80pATCIF+Y 0 MA026 TOTAL P.01 f , 4. P. 2 4F! t _ ,�,�r.,rarrarrrw�ra'�++e� P (1l .. F• n, r 1' � fi .1 ... .: def. ....-.�rwr-- � «�..��...�.rw ... _. .F`f� .+w -.. ��r �•..rMr.• 7+, +f�r.w'�r�+rrtiAw " __.' . ��:.5�-J��t'�.iv �i; �w• �il,Ca - -w ..i......., :.. w � _s �.. �r.Sw.4.I-. -� A'�n.�1•c-r'�+ ..... e f , � .�. }yY__��� ��rq Mt ,'y_ G V l '�ir41j �..�r .:f�C � �''�' H S• 3 iw�'MY i .,��..• W.i 3 a+arw.. -rt 4r..,A.. -fin .q:.,nq..t • ,.,* ---•'•--- _�•-- • � ! i y i��liysus '>f3'" SIS �t+�.'.li �. >>� ;"} ......_ . r�! _ .�„0.� N � __.” " ..» _. - U -t --- ---.._.....___•� _ I ......rr•. wr-.-�... - � -ate- _ . _ ••- Y. i k4ox 4 Ci m to IrS;,. LOT 3A AREA=2.06 AC.t 40. ft� say. 50' �0 sem,\ 106' �0. �P. FOUNDATION LOCATION PLAN CLIENT: COLONIAL VILLAGE DEV. CORP. THIS CERTIFICATION IS MADE AND UMITED TO THE ABOVE CLIENT. LOCATION:LOT 3AWOREST ST.,NO.ANDOVER SCALE: 1"=80' DA TE: 4/28/95 CHRI S TIA NSEN & SERGI PR LANDOrESSIONAL SURVEYO SEERS 160 SUMMER ST. HAVERHILL,MA. 01830 TEL 508-373-0310 ©1995 BY CHRISTIANSEN & SERGI INC. U% C 9� I CERTIFY THAT THE PRIMARY STRUCTURE SHOWN CONFORMS TO THE HORIZONTAL SETBACK REQUIREMENTS OF THE LOCAL APPLICABLE ZONING BY-LAWS IN EFFECT WHEN CONSTRUCTED. (THIS CERTIFICATION DOES NOT CONSIDER ANY 07HER RESTRICTIONS SUCH AS COVENANTS, WETLANDS,EASEMENTS ORDERS OF CONDITIONSETC) THIS DRAWING SHALL NOT BE USED BY THE CLIENT FOR ANY PURPOSE OTHER THAN THAT OUTLINED ABOVE,EXCEPT W77H THE WRITTEN PERMISSION OF CHRISTIANSEN & SERGI INC. FURTHERMORE THIS DRAWING IS THE COPYRIGHTED PROPERTY OF CHRISTIANSEN & SERGI INC AND ANY UNAUTHORIZED USE IS PROHIBITED.CHRISTIANSEN & SERGI TAKES NO RESPONSIBILITY FOR THE UNAUTHORIZED USE OF THIS DRAWING OR ANY INFOR- MATJON CONTAINED HEREON. MICHAEL 33191 DWG. NO.: 94003017 Y FORM U - IAT REIZASE FORM INSTRUCTIONS: This form is used to verify that all necessary approvals/permits from Boards and Departments having jurisdiction have been obtained. This does not relieve the applicant and/or landowner from compliance with any applicable local or state law, regulations or requirements. ****************Applicant fills out.thissection***************** APPLICANT: A1d_1 L 1�/ f -v C49,,2 PhoneIF LOCATION: Subdivision Street Assessor's Map Number '-`� 7 Parcel _ Lots) 3h St. Number /z>5a ************************Official Use Only************************ RECOMMENDA ON OFF WN A NTS: / p f Date Approved Conservation Administrator Date Rejected Comments 1l P) i U � 1 -17 -Date Approved Town Planner Date Rejected Comments Food Inspector -health Septic Inspector -Health Comments Date Approved Date Rejected �7 Date Approved Date Rejected Public Works - sewer/water connections /,J driveway permit Fire Department Received by Building Inspector Date ' Y 1 Department of Environmental Management/Division of Water Resources WELL COMPLETION REPORT t WELL LOCATION Address ZQ�t 1City/Towny;1 19 Well owners o I Address 761 5.41 PJ S l - Board of Health permit obtained: yes, no ❑ GEOGRAPHIC DESCRIPTION S oS E W of rT� (feet rclel (road) :_ N E W of (nil in tenths! (circle) intersect. WELL USE WELL DATA Domestic Q Public ❑ Industrial ❑ Total well depth ?)AD ft. Monitorings` Other Depth to bedrockS?ft. Waler-bearing rocklunconsolidated material: Method drilled Oate drilled to — Description lT✓ 'CASING jType — LengthZQ ft. Dia(.I.D.) (1) in. Length into bedrockTZ--- —f t. Water -bearing zones. 1) From Z'd To r S 2) From_ 3) From— Gravel pack well Protective well seal: Screen: Grout -E] Othe��L�_ Slot 0! To To dia. a. from_ to___. STATIC WATER LEVEL (all well�00 Static water level below land -- A2 f - sur Date WELL TEST (production wells) (�J )rawdown360 ft, after pu ping r11i. t gpm How measured, t�fleco ry f ter_! min, t LOG of FORMATIONS I COMMI`NTS Driller �4ij 1- c. L n rj a- r.i=- Firm hvellino Well & Pump Address 244A Haven Street Reading, 01867 City/Town Supervise Driller Reg.# If)� HOARD OF HEALTH COPY A • �L �o y''^•..,, , BOARD OF HEALTH ,SS'kCNUSEt NORTH ANDOVER, MASS. APPLICATION FOR WELL AND PUMP PERMIT Permit # A3 Date /goe/Z_ A A permit is requested to: drill a well install a pump LOCATION:�o2.e 3 �-- '5hZec=T Lot # Owner Lkj' -L-'+6_A-rra-;� Address 7o( 5�- Tel SUX - !0 8L- 2.!;2-0 /v- %C -t jv% Well ContrctAdd. 2-4(q,4 ff4-1eeij Tel 6e7-�V((-S�S� Pump Contrctr '` Add. v Tel << ********************************************************************** WELLS (To be completed at time of pump test.) Type of well S ✓ Use Diameter of well (P Size of casing Depth of bed rock y ) Depth casing into bedrock Seal been tested? Yes ( No (_) Date of test 1 Depth of well -300 Water -bearing rock Depth to water 9 Delivers 3 GPM for G� �fy5• (how long?) Drawdown feet after pumping housI GPM Date of completion 8 Signatur of well contractor ********************************************************************** PUMPS (To be filled in before installation.) Name & size of pump (+' �Z r�P /L Groin Type �u� per's A le -- Size of tank ZZ L Pump delivers /0 GPM Pipe used in well: Cast iron (_) Galvanized (_) Plastic) Sleeve used to protect pipe? Yes () No (�) Type well seal l rc Date_C l0 Sign _tu-re of pump installer Date water analysis report submitted to Board of Health Plumbing inspector Wiring inspector Board of Healt s .%"�• BOARD OF HEALTH ,SSA�MUSEt NORTH ANDOVER, MASS. APPLICATION FOR WELL AND PUMP PERMIT Permit # Date A permit is requested to: drill a well install a pump LOCATION: r c, a c:-,= 3-+ c�I� �=� T Lot # ownerAA-=_A-rye-t(- Address 7o( Tel Susy'- Well Contrctr /yC-�� �'� Add. Z V,4 ff�-��C.-� Tel N'� I Pump Contrctr Add. Tel << WELLS (To be completed at time of pump test.) Type of well Diameter of well Depth of bed rock Use Size of casing Depth casing into bedrock Seal been tested? Yes (_) No (_) Date of test Depth of well Depth to water Drawdown Water -bearing rock Delivers GPM for (how long?) feet after pumping hours at GPM Date of completion Signature of well 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 well seal Date Signature of pump installer ********************************************************************** Date water analysis report submitted to Board of Health Plumbing inspector Wiring inspector Board of Health ir L �� ".x jA yirt'N' � �%•'t\ w. t �. }i `+'r ai `�r�t..�R` \�r'),'At )i )i� ri ji �th� W • `, �' , { ,'t• ft�'... rrl o�x �r.g?� 5. , f� .�y.1's7 1)^ r, r.. ^1�;t3 . �.rd� r .e ., t i Town of North Andover, Massachusetts Form No. 3 BOARD OF HEALTH NORTH Ottt�rte + (� / 3? a f. _ s OL .t 1 f�•l � 9 O �'•�,,.,;.�"� DISPOSAL WORKS CONSTRUCTION PERMIT ,SS, USES Applicant 1 M a Q Lam' NAME ADDRESS TELEPHONE Site Location-��T— Permission is hereby granted to Construct or Repair ( ) an Individual Soil Absorption Sewage Disposal System as shown on the Design Approval S.S. No. Fee 'CHAIRMAN" BOARD OF HEALTH D.W.C. No. /71-4� NUMBER FEE THE COMMONWEALTH OF MASSACHUSETTS .. .. . ........ This is to Certify that --- ...... .. ................................. NAME .................. !S4�� ... -- .......................... ......... ..... .%- .................................... ........ ADDRESS IS HEREBY GRANTED A LICENSE For ....... ZZ)C-ZI- '7- ..................... ------------------------- (�E .........T ------------------- - --------- ........ ... ................................. .................. ............................................................. ...................................................... ..................................................................................................................... .................................................................................... ----------•--- -------------------------------------------------------- * ---------- - This license is granted in conformity with the Statutes and ordinances relating thereto, and expires `3_ ..... ........... ....................... unless sooners !'n�de or revo � ni ............... .. 15;" ----------........ ....... •........................ .................... lq.�� I .......... ... 7 ............. -- - ----- --- ...... FORM 433 HOBBS & WARREN, INC. ............ ---- .. �7 ........... C., ik� d c ul: uuYo UIV ✓1VIM vau Z O Z U W v1 W Z, O U W to >c m I O W � m I O k m 4 m 4 CL m `1 p J m Q to O ^ to A M A N N A A Z O Z U W v1 W Z, O U W to >c m I O W � m I O k m 4 m 4 CL m `1 p J W Z to N Q a a Q a� a�: CO o z W 0 z W 0 W o ^ b 4 0 M h v� O O O O O Q Q Q 0 2 0 0 Z 0 0 0 2 0 0 WZ O A fw o W Z O Z U W v1 W Z, O U W to >c m I O W � m I O k m 4 m 4 CL m `1 p J W Z o i -- a Q a a Q a� a�: Q o z W 0 z W 0 W o W JCl �O tyu 2 M O O O O O Q Q Q 2 Z 2 Z 2 2 2 2 C4 N to LQ J W Z (LAJ � =r WW � O W JCl �O tyu 2 M V � O `'' J O Q J W j WZ O A fw o W J Q r� vl cx`) Q W � =r WW � O Cal tyu 2 M LAA W WZ O A fw o W J Q cx`) Q OL J O o m � Q obi co W Q U W V _ y A V tf t ul uu/O UN UNII" Fdu m N O k64 LQ 4 y Q Q�i, 0 0 0 o 2 R m m Q o Q a Q Q o o h 4 4 L-44 4 2 2 0 4 4 4 4 4 w w 0 0 0 0 o Q Q ZZZZZZZ� Zt J J Q QI Pi 0 h 0 N 0 0 0 0 0 0 0 N O k64 LQ 4 y Q Q�i, 0 0 0 o 2 R m m Q o Q a Q Q o o h 4 4 L-44 4 2 2 0 4 4 4 4 4 w w 0 0 0 0 o Q Q ZZZZZZZ� Zt J QI Pi 0 h 0 N 0 0 0 0 0 0 0 N O k64 LQ 4 y Q Q�i, 0 0 0 o 2 R m m Q o Q a Q Q o o h 4 4 L-44 4 2 2 0 4 4 4 4 4 w w 0 0 0 0 o Q Q ZZZZZZZ� Zt J Cl:� O O l W 2 Q L o� Q j � ca h W O O h w� om i Q ' A ani i w w m cl : h w Q C Lli Q J`` w h FORM U - LOT RELEASE FORM INSTRUCTIONS: This form is used to verify that all necessary approvals/permits from Boards and Departments having jurisdiction have been obtained. This does not relieve the applicant and/or landowner from compliance with any applicable or requirements. *****************************APPLICANT FILLS OUT THIS SECTION******'***************** APPLICANT Ja#nl 'P414 ✓ 6Z,, PHONE 5'�-7- rho z LOCATION: Assessor's Map Number h5,0 PARCEL SUBDIVISION LOT (S) STREET1036 ST. NUMBER /0 30 ************************************OFFICIAL USE ONLY*********************************** RECDMMENDATIONS_ OF TOWN AGENTS: CONSERVATION COMMENTS TOWN PLANNER COMMENTS rRATOR DATE APPROVED /O— 3D — 0 DATE REJECTED a .TIARNI, DATE APPROVED DATE REJECTED FOOD INSPECTOR -HEALTH DATE APPROVED } DATE REJECTED SEPTIC INSPECTOR -HEALTH DATE APPROVED DATE REJECTED PUBLIC WORKS - SEWER/WATER CONNECTIONS DRIVEWAY PERMIT FIRE DEPARTMENT RECEIVED BY BUILDING INSPECTOR DATE Revised 9\97 im Io 3 z x q RqF--fv,5 S "C,/,"�tv O'C 'YX9' &�XOW pa 5r- Tia l FORM - U - LOT RELEASE FORM (7 Z,, INSTRUCTIONS:. This form is used to verify that all necessary approval /permits from Boards and Departments having Jurisdiction have been obtained. This does not relieve the applicant and or landowner from compliance with any applicable requirements. ............................................ ■ ............................. ■ ■ ✓ APPLICANT JOh Sn �-� �d ' PHONE L97 ly") NNl w ASSESSORS MAP NUMBER SUBDIVISION LOT NUMBER ►tlu:�1:7 STREET I— o c' t ST STREET NUMBER i ©13 ........:................................................................... OFFICIAL USE ONLY RECOMNIENDATIONS OF TOWN AGENTS ........................................................................... j� DATE APPROVED CONSERVATION ADMINI TOR 11191b;)- DATE REJECTED / l S b CO1yIlyIENTS �1 ��� locA-on "4b sAe- hawse w�,n lOUI TOWN PLANNER DATE REJECTED CONVVIENTS — DATE APPROVED FOOD INSPECTOR - HEALTH DATE REJECTED _ DATE APPROVED SEPTIC INSPECTOR - HEALTH DATE REJECTED C01%&1ENTS 5 -;?,0741C re5C r VC 0 r-�20- MOV �e 441GC }heA, G/JX rev) eu—) PUBLIC WORKS - SEWER / WATER CONNECTIONS DRIVEWAY PERMIT FIRE DEPARTNIENT COMMENTS RECEIVED BY BUILDING INSPECTOR DATE APPROVED DATE REJECTED DATE FA 1 'S�• 40- -t&. 114' LOT 3A AREA= 2r 06 AC-& 50' 106' FO UNDA TION L DCA TION PLAN CLIENT.• COLONIAL VILLAGE DEV. CORP. THIS CERTIFICATION IS MADE AND LIMITED • TO THE ABOVE CLIENT. LOCATION:LOT 3A'FOREST ST.,NO.ANDOVER SCALE: 1"=80' DATE:4/28/95 HRISTIA NSEN &SERGI PR FESSI NALSURVEYORSNGINEERS LAND160 SUMMER ST. HAVERHILL,MA. 01830 TEL 508-373-0310 © 1995 BY CHRISTIANSEN A SERGI INC. I CERAFY THAT THE PRIMARY STRUCTURE SHOWN CONFORMS TU THE HORIZONTAL SETBACK REOU/REMENTS OF THE LOCAL APPLICABLE ZONING BY-LAWS IN EFFECT WHEN CONSTRUCTED, ('IRIS CERTIFICATION DOES NOT CONSIDER ANY OTHER RESTRICTIONS SUCH AS COVENANMWETLANDS,EASEMENTx ORDERS OF COiA9GIf omixTC.) THIS DRAWING SHALL NOT BE USED BY THE CLIENT FUR ANY PURPOSE OTHER THAN THAT OUTLINED ABOVE,EXCEPT WITH THE WRITTEN PERMISSION Of CHRISTIANSEN A• SERGI INC. FURTHERMORE THIS DRAWING IS THE COPYRIGHTED PROPERTY OF CHRISTIANSEN & SERGI INC. AND ANY UNAUTHORIZED USE IS PRON1817EMCHRISTIANSEN A SERGI TAKES NO RESPONSIDJUTY FOR THE UNAUTHORIZED USE OF TH/S DRAWING OR ANY INFOR- MATION CONTAINED HEREON. OF MICHAEL yam;, SEgGI N 33191 Q DWG. NO.: 94003017 G r-- i .� (7N r-4 M rn �O v U/ w O w �¢ w x w z 1 U - oQn u Q v w ° w7 u o 0 V. CO a o •o c x u'. 2o w v v u c o C/) C/)' uj am 0 t (f c O CO cq W O Q rl vV D4 Z to AOS m o mOW y ~ 1--• Ea�� a CW m o c. y 0 0 o� 87 a o l y m �3p y C_ i 'O C m 3 Z C to y ca c O � m L 'O & c coy co L m y m T c>, =, x cc,* m mgr c�y o L c3`° .� Z o e 3 o s rn c c CL co CD CIO m N �C.t O C Z uj v m Im c * m c C. g y m O 'o M. I y y .co L CL CO C O CD C.) M CL CO) O V .7 CO2 0 CL cv .0 CO2 w J Q z O ni ts Cs O. COD C z co vs O •C Q O .O Cw CO CO z 1 ' .00 O i � Do L O C' CL cmQ C *-0 C tC O J •� O Z� O \ �Z co) C'J Z z z ►i cr W Z LU Q WELL DATABASE ADDRESS: l O SO AGE OF WELL: 2 AVO WELL DRILLER: WELL PERlyIIT .=: WELL LOCATION: A4, LV, r ._WELL PERNET DATE: '� �� DEPTH OF WELL: TYPE OF WELL: DRILLED b. DUG c. Li WN TYPE OF WATER BEARING ROCK: T WATER ANALYSIS DATE. — 02 G' ��^ HIGH MANGANESE: Y HIGH IRON: Y s OTEER CONTAMINANTS: Y N WELL DATABASE ADDRESS: © I F,� S AGE OF WELL: 3 WELL DRILLER: WELL PERMIT T: �%"� WELL LOCATION: DCS ,D WELL PEP2WT DATE: �� 5 ' 9 5` DEPTH OF WELT! C9 TYPE OF WELL: a.. DRIL b. DUG \_c/UNIKNOWN TYPE OF WATER BEARING ROCK: ? /YL� WATER ANALYSIS DATE: HIGH MANGANESE: N HIGH IRON: Y OTHER CONTA�M[ TANTS: Y N Hui►-c,t,�,.,.,� Q CD 0 ch CD CL M rt 0 0 E LC fD Z v A jrt G A v 0 n a 0 -h a 4 D p' n � -a cn I 0 a 0 h _ avv °0 c I m 3 77 m C ti) I rt 3 D � J t � 3 m 9 � e r� 3 rt 1 a O 7 p1 O 1 8. I [D I Q CD 0 ch CD CL M rt 0 0 E LC fD utuxuuvo uN vNimVau R.- 0 qK A w 2Ck mho 4K Q 2VwQ s 11--• $ on lc� 00 LQ to Q h L4j a ti O O O OwwV ` to pw v1 Q Q N �~�yCS O 4 4 jZLZ 'QL-44 44 LAJ Co Wl Q� 3O ` p Qqq p .J vJ o I Q 2 j 0 0 0 06 O ti 9 O 2 R 2zi �2 Q T V V k k Q4 ��W�� a, Z J W w m in Zi Q Qco w � � 4 4 4 O O� w° >-��QQ �� � V ~ O O O O O Q Q 2 Z 2 2 2 2 Z 2 2 509 — lzi w • 0 w zo , C4 � TZ Oa 4 ti Q Q IV r V + r •96� C D C T. ;+NCI -to RAI Town of North Andover, Massachusetts Form No. 1 NORTH BOARD OF HEALTH o� "'e " e - �. 13 19 � y O L A APPLICATION FOR SITE TESTING/INSPECTION Applicant /NA�M�E.� ADDRESS TELEPHONE Site Location 3.6 jn�t se Engineer Test/Inspection Date and Time Fee 03 CHAIRMAN, BOARD OF HEALTH Test No. S.S. Permit No. D.W.C. No. C.C. Date Plbg. Permit No. Town of North Andover, Massachusetts Form No. 1 BOARD OF HEALTH 'EO , 19 M APPLICATION FOR SITE TESTING/INSPECTION Applicant NAME ADDRESS TELEPHONE Site Location Engineer NAME ADDRESS TELEPHONE Test/Inspection Date and Time Fee CHAIRMAN, BOARD OF HEALTH Test No S.S. Permit No. D.W.C. No. C.C. Date Plbg. Permit No. TOAI�N OF/NORTH ANDOVER .. .... SYSTEM PUM PINO RECORL)DAI NOV 3 2004 SYSTEM to)WNFR & AnDREc SYSTEM LOCATIO -rL,MW ) Qe10 " IL :T ,ENT 7- D 30 F�OM4 3+1 NDM A-d60et) DATE OF PUMPING: /0 -9 ---QUANTITY PUMPED: 6 C0SPO()L: NO­�YES SOPUC Tank: NO_ YES NA rukb OF SERVICE: KOUTINE..._.k-�MEROENC) ObSERVA WINS GOOD CONDITION FU LL 'Iyj COVER HEAVY ()RF-ASEBAFFLES IN PLACE ROOTS LEACKPIELD RUNBACK 6XCESSIVE SOLIDSFLOODED SOLID CARRYOVER"*.-.-.-,.,-. OTHER EXPLAIN SYstvm Pwnpod by C�70 -7a. COMMENTS. CUN I LN I'S I"KANSYbRUD Ib I CHUSETTS d rvr ~� Heit��ax�� �1 he S stem ba subm,14e to the.locai•Board of W� a Y Pumping Record muse �- a ority. A: Facility lnforrfWIon r. When fang out 1 System Location"COMPU` •�;;.forjns,onthe.�; : .. ' J :.M: � �---� ony the tab key Address 1030 to move your':; . ' �.: •. �i1�//LfO�,� cursor • do not ; - `usi the rotum' .% CIt�ITown , .. Sta .ksy t..l: 'y;a;:,:�;,� :. ,,�%=i•.:;; •'•'� •-:�,.•,.:; ,.: �..'. a .. FP Code. .System ""' �''� ;�� Address pf dlNerent from bcatlon) . , • Ctty/toum:.'a; State Code ... ..I•• .. ,.. T816phptle ►•lurpb9r :pumPlPg:.RdQ-6rd: �!Ji: ;,'• ;2�'r' v: r:R%:•L" ° Jai u,. Y' ( `1 X1::•,%•1..'%.'!i":•�r��•;%'?jA V>:�" ''t; "1�'%' �,•••�''' � �©� ,•� %• r 1;' Dafe of Ptimpin�' Date 2. Quantity Pumped: p Gallons Type pf,system:; ❑ Cesspools) Septic Tank :. ❑ Tight Tank ]'f Other (describej; , ffluentTea'Flite r E { p sent? .❑ Yes ❑ No • If yes, was It clean ed? ❑Yes ❑ No r:+:Sr:-,' Co�ditlon`o(:S m• .. _ .. •..t.' .•e.u�: .: *:: ' •�•u Iia%!��, i �..: n.tq�,r, J' • '.!' ..n,: •. .�7.'�,l.:.,,, ��''��• ' I"r.••.^'•,. .. //may /) .._� ,',i:,�.'.?1:4�;�7{!'.;Y.;'4vlrj'{'.b:%(,,dS7'!4•l•.ti �l••l.\.,'... �L • ',° :...:. 8;";':.Sy TTPumped By; •�,.h j.. .:� ': �;>. {�•, fir,, � t.' y-y�.p'•>,F.i Y1j � � r;; i�.• / ✓.i :•'" f"•• r::%: �•,.:7:%In'LS;.,., ,i,�.ut4i1,�;+,1•, ,••. {Ira4,l:'.+��,:ii,�n'.J.'.:, '•+'•'•; :`'Y„`{r•�i•. 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