HomeMy WebLinkAboutMiscellaneous - 230 LACY STREET 4/30/2018 (2) D
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NORTH ANDOVER, MASS. C,
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APPLICATION FOR WELL AND PUMP PERMIT
Permit # Date ! U o
A permit is requested to: drill a well install a pump
LOCATION: 3
U (� C S � .
Lot
of
1 OwnerCAAo(. JT• j�wt,P S Address -2 -5Q L44cy �F'= Tel � 7�-V7 V- Z YS>y
Well Contrctr AOLLJ,✓S _T r/c. Add. IaR 0c, O, ,v(19, Tel
Pump ContrctrS 'C Add. Tel
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WELLS (To be completed at time of pump test. )
Type of well Use
Diameter of well Size of casing
Depth of bed rock Depth casing into bedrock
Seal been tested? Yes (_) No (_) Date of test
Depth of well Water-bearing rock
Depth to water Delivers GPM for
(how long.
Drawdown feet after pumping hours GPM
i
Date of completion
Signature of . 1 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? Yves (_) 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
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,SSACHUSEt
THE COMMONWEALTH OF MASSACHUSETTS
TOWN OF NORTH ANDOVER
BOARD OF HEALTH
Permit # 023
Fee: $50.00
Date: 11/15/01
This is to certify that: C.M. Rollins, Inc.
IS HEREBY GRANTED A LICENSE
FOR THE PURPOSE OF DRILLING A WELL AT:
I
230 Lacy Street
This license is granted in conformity with the statutes and ordinances
relating thereto, and expires DECEMBER 31, 2001 unless sooner
suspended or revoked.
Ga on'Osgood, Chairman
Francis .-4,-cMillan�M.D., Meme J
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' IUXT14 AkIDOPFe, MA66.
WALE /"•Go' DATE ; Nod li, t98 3 _,J4�
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CHARLES
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L AWPe UC E, MA8s. No 1732�Q
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Oct-31 -01 09 : 12A chemwood 798 372-0973 P . 01
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TOWN OF
NORTH .ANDOVER
' SYSTEM PUMPING RECORD
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SYSTEM OWNER&ADDRESS
SYSTEM LOCATION
�r 2 (exaipple: eft`front of house)
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Pit,
L irt. r }c.• `:i ,4�r, ,r y, ..._. _ .. r•: ..NA ,t'`JATF'OF PUMPING; h'�zJl
�. 'QUANTITY PUMPED D0t3 GALLONS •
" �,. �dF yty 4"t�..��S t�• it i •r F n...i i r S ' {I i: _ .
�S$POOL:
NO IYES SEPTIC T , YES
---- _.� ANK: NO
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• ,�.,�. :�' .OF SERVICE;. ,ROUTINE % ..,, •
EMERGENCY
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VAT
ons
p5w � GOOD COND ITION FULL TO COVER
HEAVY GREASE BAFFLES IN PLACE
ROOTS _
EXCESS �CH�LD RUNBACK
,i '
EXCESSIVE SOLIDS FLOODED
i< t" , 't' ';; }c`:i CARRYOVER
:. :> , ,; SOLIDS CARR OTHER(EXPLAIN)
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ORTH ANDOVER MASSACHUSETTS
Pump .,g cded
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DEP,has provided this form for use by local Boards of Health. The System Pumping Record rrlusc
be submitted to the-Iocal, Board of Health or other approving authorityt.
A: Facili SEP
ty Inforrotion
• .f TY!�n�p out :1:. System Location / �--�
~
'.ordy the tab key Address
to move your:; , J
atrsoc•do dot Cl /Town
use the return + tY•. A0
State Zip Code
System
OWner;
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Address(if different from location
) . .
CitylTown State
ode
Telephone Number
Pu In R r.
mp gegord
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14 Date-of Pump(n z `
; pat 2 uantity Pumped: canons
system;, ❑ Cesspools)
Septic Tank
P ❑ Tight Tank
LT'Other(describe);
Effluent Te9 Fiiter present? ❑ Yes.❑ No If yes, was if cleaned? ❑ Yes ❑ No
Cohdition'of:S sf
y
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'6.'_.Sy A�r�•�' Pumpedl6yr"''
Ucen
ie Number
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tion where contently. were dIpposed:
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';.,`:;?�;:;'�:. ,�:.: Slpnature of Hauler;i�•�..';,; ;, t' Date
httpJ/www;mass.9ov/depJv✓afer/approvals/t5form s,h tm#inspect
t5forrM.doa•OQJ03 `
System Pumping Record Page I of 1
i
NOV3 2004
I'OOF" NORTH ADOV f, TOWN OF NORTH ANDOVER
SYS M/PUMPINQ RECORD HEALTH DEPARTMENT
UA.Ik \ /
SYSTEM OWNER.& ADDRESS SYS EM AT70
a� LQcy s�
JV d C1fupDUP�, Q�
DATE OF Pl1MPtNG: d - --
_..._....._......_' _-....._U:.IANTITY PUMPED: l �
. ...... . ..... ... .
C LSSPOOL: YE5 Stlpuc Tank: NOY
�'""'.:: ... _ b
NA fURb Or SERVICE(ROU'rlN ".....__ __....EMERUENC;'Y
OBSERVATIONS-
Cl•OOD CONDI'T l PUL..L 'TY) COVER +►,
HEAVY OREASB BAFFLES IN PLACL
ROOTS _
BXCESSIVE SOLIDS ....__ OODEDD RUNBACK
SOLID CARRYOVER,_... OTHER EXPLAIN
sy.usm Pumpcd by
CUMMENT5.
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- .......... .
CUN 1'EN I's CKANSk-bKREL) I'L)
Commonwealth of Massachusetts FECEIVEDCity/Town of North Andover P 1 2 2011
System Pumping Record TOWN OF NORTH ANDOVER
Form 4 1 HEALTH DEPARTMENT
�M
DEP has provided this form for use by local Boards of Health. Other forms may be used, but the
information must be substantially the same as that provided here. Before using this form, check with your
local Board of Health to determine the form they use. The System Pumping Record must be submitted to
the local Board of Health or other approving authority within 14 days from the pumping date in
accordance with 310 CMR 15.351.
A. Facility Information
Important:
When filling out 1. System Location:
forms on the 2_7-i-�) a&-- .
computer, use
only the tab key Address
to move your N.Andover Ma 01845
cursor-do not
use the return City/Town State Zip Code
key. 2. System Owner-
Name
wnerName
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record �s
1�
1. Date of Pumping I 2. Quantity Pumped:
Date Gallons
3. Type of system: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes ❑ No IfY es, was it cleaned? ElYes ElNo
5. Condition of System: C�
6. tem PumpegB�---
Name Vehicle License Number
Stewart's Septic Service
Company
7. Location where contents were disposed:
Stewart's Pre-treatment Plant, 20 So. Mill Bradford, Ma 01835
na re of Rau er Da
Ell
Signature of Receiv ng,Fac V y Date
t5form4.doc•03/06 System Pumping Record•Page 1 of 1