HomeMy WebLinkAboutMiscellaneous - 2237 TURNPIKE STREET 4/30/20180.
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SEPTIC SYSTEM INSTALLATION
IS THE INSTALLER LICENSED? , YE NO
TYPE OF CONSTRUCTION: NEW PAIS
NEW CONSTRUCTION: CERTIFIED PLOT PLAN REVIEW YES NO
CONDITIONS OF APPROVAL YES NO
(FROM FORM U)
ISSUANCE OF DWC PERMIT K--'YE—S--NO
DWC PERMIT PAID?y&--:'� NO
DWC PERMIT NO. INSTALLER:,v 0566o,n JP -
BEGIN INSPECTION �— NO:
EXCAVATION INSPECTION: NEEDED:
PASSED /%/ —/Z :: � - BYV
CONSTRUCTION INSPECTION: NEEDED:
AS BUILT PLAN SATISFACTORY: YES:
APPROVAL TO BACKFILL: DATE:4
FINAL GRADING APPROVAL: DATE
BY
BY
FINAL CONSTRUCTION APPROVAL: DATE:4L--BY
FORM 4 - SYSTEM PUMPING RECORD
Commonwealth of Massachusetts
Massachusetts
System Pumping .record
PCO, C� .1 ci.vv , ✓1� cti .
Type: Emergency ElRoutine 0"
Cesspool: No ltd/Yes ❑ Septic Tank: No ❑ Yes ❑�
Date of Pumping:�lS �U Quantity Pumped: /s o gallons
System Pumped by (Company): f
Permit 9:
Contents transferred to:
.Contents disposed at:
CO G S J
Date 5 5 03 Pumper Signature �
Condition of system/other comments:
�Co �J7
7 2003
DEP APPROVED FORM - P10719S
FORM 4 • SYSTEM PUNVING RECORD
Commonwealth of Massachusetts
'Massachusetts
S�� ct� in OCT - 9 2001
v ern 179ittion
Type; " Emergency 0 Routine C9!
Cesspool: .No �' Yes ® Stptie 'Tank: No. a Yes
7.1
Dace of Pum*l: - Quentinp Pumped- gallons
System Pumped by (company): ' y a- Permit —
Contents transferred to:
Contents disposed at:
Date' Pumper Signature C..
Condition of sys;emlotiser .comments:
Do AiPROVW mj6q • taivisi
CURRIER
SEPTIC & DRAIN SERVICE
107 FOREST STREET; MIDDL ETON, MA 01949
(978) 774-2772
NWEALTH OF MASSACHUSETTS
MASSACHUSETTS
SYSTEM PUMPING RECORD
SYSTEM OWNER: I SYSTEM LOCATION:
DATE OF PUMPING: QUANTITY PUMPED: i 1[ D GALLONS,
y'L�l
CESSPOOL: NO YES a SEPTIC TANK: NO YES
SYSTEM PUMPED BY: CURRIER SEPTIC & DRAIN SERVICE
CONTENTS TRANSFERRED TO: v�
DATE: d INSPECTOR:
0R
T4Wi s YER/
�C?�RCZ OF ce
JU�J 0
1999
t/
r�
FORM U - LOT RELEASE FORM
39'(
WX
I RUCTIONS: This form is used to verify that all necessary approvals/permits from
B ards and D.�n, artments having jurisdiction have been obtained. This does not relieve
applicant and/or landowner from compliance with any applicable or requirements.
***"APPLICANT FILLS OUT THIS SECTION*
PLICANT AdPHONE tl,97-7271
LOCATION: Assessors map Number 088 PARCEL
SUB01VISION LOT (5)
ST. NUMBER
*"OFFICIAL USE ONLY*______
RECOMMENDATIONS OF TOWN, AGENTS:
CONSERVATION ADMINISTRATOR DATE APPROVED
PATE Rl JECTED
COMMENTS
TOWN PLANNER DATE APPROVED
DATE REJECTED
COMMENTS
FOOD INSPECTOR -HEALTH DATE APPROVED
DATE REJECTED
TH DATE APPROVED
DATE REJECTED
COMMENTS4-'l D,
PUBLIC WORKS - SEWERIWATER CONNECTIONS
DRIVEWAY PERMIT
FIRE DEPARTMENT
RECEIVED BY BUILDING INSPECTOR
DATE
of ttI
.D=/3:=x ---/ .
�
e- / Al (::3
-7
William F. Weld
Go,omor
TrudyCoxa
Secrotnry, EDEA
David B. Struhs
Commissionei
Commonweafth of Massachusetts
Executive Office of Environmental Affairs
Department of
EnAr nmental Protection
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION
OCT 101995
Property Address: "���i/1/o���iiclD�fr,, Address of Owner;
Date of Inspection: 10114191,(If different)
Name of Inspector:
Company Name, Address and Telephone Number:
CERTIFICATION STATEMENT /9'l alo'llze, #19
I cenii), that l have personally inspected the seto age d,spcsal system at this address and that the information reported be.lo.+ is true, accurate
and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and
maintenance of on-site sewage disposal systems. The system;;
Passes
Conditionally Passes
Needs Further Evaluation By the Local Approving .Authority
a�FaiIs
Inspector's Signature: t /, Date:
The Sv- zem Inspecor sha!I submit a copy of this inspection report to the Approving Authority within thirty (30) days of completing this
insr)ectio;' If the s) sten' is a shared system or has a design flow of i o.00Q gpd or greater. the inspector and the system ovti netshall submit
thh. repot to the appropriate regional office of the DePartn(-rt of Eng ironmcntal Protectio^
1 he pnf?Jnai SI1UUIr,7 be se.n. tc. tt Ce anG Coif sen, to t.- c appir;&'t,�, and the appro^'in
INSPECTION SUMMARY:
Check A, B, C, or D:
AJ SYSTEM PASSES: -.
I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303.
Any failure criteria not evaluated are indicated below.
B) SYSTEM CONDITIONALLY PASSES;
One or more system components need to be replaced or repaired. The system, upon completion of the replacement or repair,
passes inspection.
Indicate yes, no, or not determined (Y, N, or ND). Describe basis of determination in all instances, If "not determined", explain why not)
The septic tank is metal, cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank failure is
imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as
approved by the Board of Health.
(revised 8/15/95)
One Winter Street o Boston, Massachusetts 02108 m FAX (617) 555-1049 S Telephone (6.17) 292 -SSW
. -;w P—w. on Recycied Pipet
R
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property. Address:
Owner: 1�o Q5 �4 / 114
Date of Inspection:
BJ SYSTEM. CONDITIONALLY PASSES (continued)
Sewage backup or breakout or high static water level observed in the distribution box is due to broken or.obstructe'd
pipe(s) or due to abroken, settled or uneven distribution box. The system will pass inspection if (with approval of the:
Board of Health):
broken pipe(s) are replaced
obstruction is removed
distribution box is.levelled or replaced
The system required pumping more than four times a year due to broken or obstructed pipets). The system will pass
inspection If twit`, approval of the Board of Health)
broken pipe(s) are replaced
obstruction is removed
CJ FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:
Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the
public.health, safer; and the environment.
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER
WHICH "'ILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
Cerspoc� cr prr,•', is within 50 feet of a surface water
Cesspool o: pr;ti', i> v.ithin 50 feet of a. bordering vegetated wetland or r salt marsh.
2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH:(AND PUBLIC "'ATER SUPPLIER, IF APPROPRIATE) DETER:NAINES THAT
THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE
ENVIRO'\ME`T
Thi- < ae. nac a septic tank ano smi aoboroiion sysl,enl ano is vviol;n 103 ieei iu d :ulf�4c "dic: qui,, G' it LiuiAr) , ,
Sept lc -tank. and snit absorption system and is within a Zone I of a public water supply
The s sr6 r f as a septic tank and soil absorption system and is within 50 feet of a private water supply well.
i he ;, t:a-, 3 ,eptic tank and soil absorption system and is less than 100 feet but 50 feet or more from a private late
slip +e!1, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is
free from poilut on from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5
ppm.
DJ SYSTEM FAILS:
I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis
for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct
the failure.
Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool
%f% Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or
cP.sspool.
(revlsed Sig:/Si.
2
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address:d,.5�`
Owner /l/ o es R/
Date of Inspection:D)'SYSTEM FAILS (continued);
Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool.
Liquid depth in cesspool is less than 6" below invert or available volume Is less than 1/2 day flow.
XV Required pumping more than 4 times. in the last year NOT due to clogged or obstructed pipe(s).
Number of tames pumped
An} -oHion of the Soil Absorption System, cesspool or privy is below the high groundw,4ter elevation
portion of a cesspool or pmv is within 100 feet of a surface water supply or tribu.ta to „ face water supply
Ani porton of a cesspool.or privy is within a Zone I of a public well
rU Any porion or a cesspool or privy is within 50 feet of a private water supply well.
/U Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no
acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for
coliform bacteria, volatile organic compounds. ammonia nitrogen and nitrate nitrogen.
El LARGE SYSTEM FAILS:
The foil0:•,fne criteria appy, to large systen-.s in addition to the criteria above
The design Cc;•, of s}rte^ is 10,000 gpd or greaterd, System`, and the wstem i5 a significant threat to public health and safety
and the environment because one or more of the following cond;tions exist.
the system is within 400 feet of.a surface drinking water supply
the system is vlythm 200 feet of a tributary to a surface drinking water supply
_ the ysten) is located in a n trogen sensitive area Unterim VVelihead Protec-tion; .Area (NYPA) or a rnapped2one II of i
uub;,r water v,eil'.
The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program
requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information.
rrevaed l/iSi95; 3
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
///
Property Address: �2�3? 7_p e j Pl'l((T rl'l %✓,)ZT 4 4'*
Owner:�.h�,l/
Date of Inspection: �to
Check if the follokcing have been done
t/ Pumping information was requested of the o,.vner, occupant, and Board of Health.
None of the system components have been pumped for at least two Meeks and .the system has been receiving normal flow rates
during, that period, large volumes of v,ater have not been introduced into the system. recently or as pan of this inspection.
As built plans have been obtained and examined. Note if they are not available with N/A.
The facil tv or dv,e!ling .vas inspected for s gr.s of sewage back-up.
Thesystem does not receive non•sanitar`' or industrial waste fiow
,The sae .vas mspecied for signs of breal:ou+
r
All system components; excluding tht� Sot! .Absorption System: have been located on the site.
The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or
tees, material of construction, dimensinns, depth of liquid, depth of sludge, depth of scum.
✓ The size: and location of the Soil Absorption System on the sate has been determined based on existing information or
appr(7.x!,n-zed b\ .ion-!ntrus ve meti•l;)d
The. C' tir,.r> �., o,� "formation on the prnner maiwenance.Of Sub -
Surface tD!soosal System.
tx'ev:sed 8/15/95} 4
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address:
Owner:
Date of Inspection:
FLOW CONDITIONS
RESIDENTIAL.:
Design flow: gallons
Number of bedrooms:'_
N:ambe; of current residents:
If -
Garbage grinder (yes or no).
i
Laundry connected to system 'yes or no): -L
Seasonal use (,yes or no):.
Water meter readings, if available:_w
:.ast date of occunac-,c','
COfNMERCIAIIINDUSTRIAL:
Type of establishment:
Design flow:_______gallons/da'y
Grease'trap%present: (yes.or noi_.__
Industrial Waste Holding Tank present. (yes or no!—
Non-sanitary waste discharged to the Title 5 system: (yes or noi—
Water meter readings, if avaiiaole; - --
Last date of gCCupancy
OTHER: (Describe;
Ld"St dace 'Di ucCt,1''Ili
GENERAL INFORMATICJN
PUMPING RECORDS ands .u,ce of information: I�^
System pumped as pa.^, of inspection: (yes or.no),go
If yes, volume p... ;r. r' gallons
Reason for pumpir•g. -
TYPE OF SYSTEM
Septic tank/distribution box soil absorption system
Single cesspool
Overflow cesspoci
Privy
Shared system (yes or not (if yes, attach previous inspection records, if any)
Other (explain)
APPROXIMATE AGE of all components, date installed (if knov.,n) and source of information: // 112—
Sewage odors detected when arriving at the site: (yes or no)
Irev:s,d H; 15!9" �
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART .0
SYSTEM
�� INFORMATION (continued)
Property Address: ��3`7 �G''�/t%�i/{/% �'4,10Gt'7' 9,46 vie, /* x,
Owner: 4/0 0_5 � i ✓�A; he,
Date of Inspection:
/
SEPTIC TANK:_
(locate on site plan)
Depth below grade:
Material of construction �Zconcrete _metal _FRP _other(explain
Dimensions:
Sludge depth; /p "
Distance from top of sludge to bortonn of outlet tee or baffler
SCUM thickness: 4 _
Distance from top of scum tq top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet lee or baffler_
Comments
;recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural
integrity, evidence of leakage, etc.; 9h X ,l'o o. ri'en /Gi DeeGl�C
rf-i Qi. � /� �r/I N, i// w.�' GJY,/ ..s/"' IL s" � ♦ %�. v
GREASE TRAP:..
oC'te on site 'plan'.
Depih beloti% grade.
Material of construci:on _,concrete metal ,FRP other(explaiw
D mensions-
�cu:n
Djstance from top of scum to too of outlet tee or baffle:
Eli-ance fro bottn n n' <rim r hn'f,,-rr .0' outlP' tee or banie
Comments .
trecommendation fo• pumping, conci.t,on of inlet and outlet tees or baffles, depth of liquid ievel in relation to outlet inver, structural
integrity, evidence of lea�age, etc.:
,revised 6/i5/95 6
iUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 2✓,.� % �YJ � n iV''n Cf � � ��' ��'�
Owner:
Date o'f"Inspection;
TIGHT OR HOLDING TANK;
(locate on site plan;
Depth below grade:
Material of con$truction: concrete _meta! —FRP _—other(explain).
Dimeri5;ons:
Capacity: gailons
Dee ign ffcvc: gallor`s;'da"
Alarm level.
Comments:
(condition of inlet tee, condition of alarm and float switches, etc.)
DISTRIBUTION BOX:
Oo,:.'ie �J ,'1 site plane —.
Depth of liquid level above. outlet invert: L �141
Comments:
P �i m. r+,,^.� F Cr cnl;_�; C'•'� t`\'P P" idence o! leaf -age !n)O or OU! Of I70x. eK-t -
PUMP CHAMBER:
(locate on site plan
Purnips in working order:;yes or no
Comments:
(note condition of pump chamber, condition of pumps and appurtenances, etc.)
!rev. ed 6/15;'95) 7
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: C2'i 7 n r ee S r t
Owner: /Ye CST%9h�° y
Date'of Inspection;
SOIL ABSORPTION SYSTEM (SAS):
(locate on site plan, if possible; excavation not required, but may be approximated by non -intrusive methods)
If riot determined to be present, explain:
Type:
leaching: pits, number;_
leaching chambers, number:____
leaching galleries, number:
leaching trenches, number,length:________
leaching fields, number, dimensions:
overflow cesspool, number.!_
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,etc.;
CESSPOOLS:
(locate on site pian)
Number and configuration:
Depth -top of Liquid to inlet invert: _
Depth of solids layer.
Depth of scum laver:
,m"!eria'S of construC;.On
inflov,, most be Glin`ped as pan ofinspection)_
Comments: (note cond;uon of so 1, signs of hydraul c fa lure, level of ponding, condition of vegetation, etc,?
PRIVY: _
(locate on site plan;
Materials of construction: Dimensions,
Depth of solids:
Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
t:evised ai15!s5; 8
r �
Y
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address:
Own0;- i'���5 1,4? /fie y..
Date of Inspection:
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100`
I
i a ox
Town of North Andover °f N° DTN
OFFICE OF 3� 5°' 0oma
COMMUNITY DEVELOPMENT AND SERVICES °
F p
40 «
146 Main Street
KENNETH R. MAHONY North Andover, Massachusetts 01845 9SSACHUSE�
Director (508) 688-9533
TOWN OF NORTH ANDOVER
BOARD OF HEALTH
November 21, 1995
CERTIFICATE OF COMPLIANCE
This is to certify that
the individual subsurface disposal system
constructed ( ) or repaired (X)
by Benjamin Osgood, Jr.
installer
at 2237 Turnpike Street, North Andover, Mass.
has been installed in accordance with the provisions of TITLE 5 of
the State Sanitary Code and with Board of Health regulations as
described in the Design Approval Permit # 782 dated Oct. 24, 1995
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A
GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORILY.
Board of Hedith Inspector
BOARD OF APPEALS 688-9541 BUILDING 688-9545 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535
Julie Parrino D. Robert Nicetta Michael Howard Sandra Starr Kathleen Bradley Colwell
PLAN REVIEW CHECKLIST
ADDRESS Aa3 7 7ZIelyPl�---ENGINEER
GENERAL
3 COPIES STAMP LOCUS NORTH ARROW � SCALE
CONTOURS PROFILE SECTION_Ln,- BENCHMARK SOIL &
PERCS ./ ELEVATIONS WETS. DISCLAIMER, WELLS & WETS i
WATERSHED?A6 DRIVEWAY (Eley) WATER LINE L_- FDN DRAIN
SCH4 0 TESTS CURRENT? SOIL EVAL J - S
SEPTIC TANK
MIN 1500G�.17 INVERT DROP GARB. GRINDER(+200% EDF)
25' TO CELLAR — MANHOLE ELEV GW # COMPS.
D -BOX
SIZE # LINES A FIRST 2' LEVEL STATEMENT L,--'
INLET.4j4- OUTLET- =--rE76_ (2" OR .17 FT) TEE REQ'D?Al
9730 q7-4_-'55 ,/7
,/� C&
LEACHING il6
MIN 660 GPD? RESERVE AREA 4,"�4' FROM PRIMARY? ® 20 SLOPE
100' TO WETLANDSI_✓ 100' TO WELLS &,'-' 4' TO S.H.GW -__� (5'>2M/IN)
35' TO FND & INTRCPTR DRAINS 325' TO SURFACE H2O SUPP
4' PERM. SOIL BELOW FACILITY �� MIN 12" COVER L --FILL? (25'
if above natural elev; 101if below) BREAKOUT MET?
TRENCHES
/
MIN 660 gpd
SLOPE (min .005
or 6"/100') ✓
SIDEWALL DIST. 3X EFF.
W OR D (MIN 6')
L,----
,- RESERVE BETWEEN TRENCHES?
`__ IN FILL?4� MUST
vQ�rBE 10' MIN.04-
4" PEA STONE? b16
VENT? -
(>3' COVER; LINES >501)
BOT --276 +
SIDE v<�6 X
LDNG - J�3 =
TO <3,3.
(L x W x #)
(DxLx2x#)
(G/ft2)
Copyright tj 1995 by S. L. Starr
gORTq
O at�aao �a,�0
H M
p
SSACMuSEt
Applican
Site Location
Town of North Andover, Massachusetts
BOARD OF HEALTH
Form No. 2
DESIGN APPROVAL FOR
SOIL ABSORPTION SEWAGE DISPOSAL SYSTEM
11
Reference Plans and Specs. l rte,
ENGINEER
Permission is granted for an individual soil absorption sewage disposal system to be installed
in accordance with regulations of Board of Health.
Fee
A MAN, BOARD OF HEALTH
Site System Permit No.
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THE COMMONWEALTH OF MASSA CHUSETT
TOWN OFNORTHANDOVER
BOARD OF HEALTH
Permit #
This is to certify that Viera Well Company
IS HEREBY GRANTED A LICENSE
For Well Installation, a7-2-23 f Turnpike St--r-Ret--
This license is granted in conformity with the statues and ordinances relating thereto, and expires
DECEMBER 31, 1997 unless sooner suspended or revoked.
¢Member
John k
L-001
BOARD O1' HI_`AU1T1
Town of North Andover,Mass.
Permit 199
APPLICATION FOR WELL & PUMP PERMIT•
Application is hereby made for permit to drill a well (41/). Application is
made to install (_) a pump system.
Location: Address Z?%3'7 Lot #�
Owner4Cp�Z/ IJ�'AC'an/'�- 13u�/�,�'2 Address e,?3i%` /c�2iy�f/�,E 9 f 'Tel.
Well Contractor V -0r, (16' Address ?5'3A,,Ydc' -6e 5T CM Tel .Y57(? JS,RC-
Pum Contractor 01 r
p �m�n��T®� �„�� A d d r e s s �,� 9 G(,io,Qo'P✓i � S" G� �(. �Q T e l• •�.S� 9f �' f
WELL CONTRACTOR .(To be completed at time of pump test)
Type of Well Well used for
Diameter of Well Size of. Casing
Depth o£ Bed RocIt Depth casing into Bed Rock
Was Seal Tested? Yes (—) No (—) Date. of Testing
Depth ••o- Well — _. Well Ended in What. Material r
Depth to Watex Delivers Gals.Per Min. for 4 hour_:
Drawdown feet after pumping hour -at PTI
Date of* Completion
Signature Well Contractor
PUMP INSTALLER (To be••fi.11cd Ln- before installation) r
Size & Name Pump _Pump Type Used
--
Water Pump Delivers GPM Size of Tank
Pipe Material Used in Well: Cast Iron ( ) Oniv.1ni.zed ( ) Plastic ( )
Well Pit: (_) or Pitless•Adapter ( )
Was sleeve used to protect pipe? Ycs (—) NO(—) Type or Name Well Seal
Date
I�C�,„t,`, ,y�tth�4v4
Date Water analysi"s repdr-t• 'submitted to Board of I•real•th
Date release given tD owner of record & Bldg. Insp
Health Inspector
THE COMMONWEALTH OF MASS
TOWN OFNORTHANDOVER
BOARD OFHEALTH
WELL DATABASE
ADDRESS:
ACE OF 7, VE L L WELL DRI -11.111=.
F ERL'YE-1 T: WELL - LOCkTION:
'W'= PER&= DA7,=-:- DE27E OF
=E OF WE'LL a-. DRILLED b. D c-
=F-OFWAIE-11BE.224G ROCK -
WA=. A -IL, TA- LY = I D A=- -- HIGHNIAN(lk'L'IEESE: y
Y- y cGN7A-NMTk=L. y N
7.y-= DATA 3.A -EE
ADDRESS:
.4 -c -E OF 7y=1:
L=l
NII IT DIATII E:
TYPE OF WHELL: DKILLED
TYPE OFWAJERBEARLNG ROCK:
NATER .Ai,N'ALjYSIS DATE: lEcH y
PZGH IRON: y NN OTl---7R CONTA.NLf2qA-N,-TS: y
Cl
'Wl=-=- E)R==EP-
DEP7,H OF WELL
DUG c. UL\FKNi 0 "W NL