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at* „r "`'�h PLA4N APPROVAL: DATE l / ill ARP. BY;
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WELL PERMIT' DRILLER
WELL TESTS: s CHEMICAL DATE APPROVED
BACTERIA I DATE APPROVED �
BACTERIA II DATE APPROVED,
COMMENTS:
t, FORM U APPROVAL: APPROVAL TO ISSUE YES NO
I DATE ISSUED o
-FINAL APPROVAL:
rl ALL'PERMITS PAID NO
'WELL. CONST RUCTION APPROVAL:' NO
.:..SEPTIC SYSTEM CONSTRUCTION APPROVAL �Si NO
OTHER YES NO
ANY VARIANCE NEEDED YES NO
FINAL BOARD OF HEALTH APPROVAL: DATE: BY:
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SSUANCE
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JCTION:'— CERTIFIED" PLOT.,: PLAN ":REVIEW-.',
YES NO
CONDITIONS OF APPROVAL
YES NO
(FROM FORM U)
-DWC,PERMIT
NO,
INSTALLER:
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BEGIN" -INSPECTION 4 YES NO:
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EXCAVATION ,'INSPECTION: -.,",,"-.,NEEDED:
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APDATE DATE: E:
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FINAL CONSTR
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f 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.
i
*****************************APP'LICANT FILLS OUT THIS SECTION***********************
APPLICANT e��"t [�O { PHONE
LOCATION: Assessor's Map Number 161 /i PARCEL c9e-<)"7
SUBDIVISION LOT (S)
STREET 2.4// Facrh� S'� ST. NUMBER
USE ONLY*************** ******
RECOAENDATION,S OF TOWN AGENTS: I
RVATION ADMINIS TOR DATE APPROVED
DATE REJECTED
COMMENTS
TOWN PLANNER
COMMENTS
DATE APPROVED
DATE REJECTED
FOOD INS C -HEALTH DATE APPROVED
DATE REJECTED
1ASftCTOR- ALTH DATE APPROVED
DATE REJECTED
COMMENTS
PUBLIC WORKS - SEWERIWATER CONNECTIONS.
DRIVEWAY PERMIT
FIRE DEPARTMENT
RECEIVED BY BUILDING INSPECTOR DATE
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66 LITTLETON ROAD WESTFORD, MA 01886 (508) 692.8395 FAX (508) 692-0023 1 -800.649 -TEST
Report Number: C-sks-7485 Report Date: Dec. 07, 1992
Client: Sample Taken At:
Mr. Roger Skillings Messina Development
Skillings and Sons Lot 5AA
269 Proctor Hill Rd. Farnham Rd.
Hollis NH 03049 N. Andover MA
Sample Taken By: SKS Staff On: December 04, 1992
CERTIFICATE OF ANALYSIS
TEST PARAMETER:
EPA Max
RESULTS
UNITS
Total Coliform (P)
0
0
Per 100ml
Calcium
No Limit
16.2
mg/L
Copper (S)
1.3
0.08
mg/L
Iron (S)
0.3
# 0.37
mg/L
Magnesium
No Limit
5.6
mg/L
Manganese (S)
0.05
# 0.18
mg/L
Sodium
" 20
15.3
mg/L.-
Potassium (S)
No Limit
1.7
mg/L
Alkalinity (S)
No Limit
66
mg/L
Ammonia
No Limit
<0.03
mg/L
Chloride (S)
250
13.2
mg/L
Chlorine (total)
0.7
0.31
mg/L
Color (S)
15
# 30
CPU
Conductivity
No Limit
216
umhos/cm
Hardness
No Limit
64
mg/L
Nitrates(as N)(P)
10
<0.01
mg/L
Nitrites(as N)
1
<0.01
mg/L
PH (S)
6.5-8.5
7.7
SU
Odor (S)
3
2
TON
Sulphates (S)
250
12.8
mg/L
Turbidity
5
1.2
NTU
Sediment
pos/neg
pos
NT=Not Tested, #=Value Exceeds EPA STD, TNTC=Too Numerous to Count
*=Background Bacteria Noted, "=EPA Advisory Limit
'=Exceeds EPA Advisory Limit
(P)=Primary EPA Standard, (S)=Secondary EPA Standard (may affect
aesthetics of drinking water i.e. taste, color, etc.)
This water sample, as tested, is considered SAFE to drink according
to EPA guidelines. However, one or more of the parameters exceeds
EPA secondary standards as indicated by the (#) sign.
Massachusetts State Certifiedic/e�rl��
MicH'ael P. Carlson, for
Testing Laboratory #MA048 Thorstensen Laboratory Inc.
AS -BUILT CHECK LIST
and
FINAL INSPECTION
Proposed Elevations
House
Tank IN 5g -.M'56
Tank OUT 07, 5�5
D -box IN
D -box OUT ,4a, 33
Trench Inverts
Line 1
Line 2
Line 3
Line 4
As -Built Elevation
�
43,3
4a
Bottom of Exc.
Stone OK? D -box checked?_z Pipes cemented?
96
Department of Environmental Managemei
k,,, , •'r"' WELL COMPLETION REP
WELL LOCATION
Address
14? &
City/Town.A?z{
Well owner��
GEOGRAVHIC DESCRIPTION
r���
s E w or
(circle)
./.ry . 44
rroaal'g�''
N of
rnu. m nths) el
Board of Health permit obtained: r yes � no El w/ n.CG
(road
WELL USE "tobediock
Domestic P-P.blic ❑ Industrial ❑ :3,00 ft.
Monitoring ❑ Other 1 ft.
inconsolidated material:
Method drilled
Date drilled—
CASING
Type✓
Length__ft. Dia(.I.D.)__6_—in.
Length into bedrock 96
Protective well seal:
Grout.[] Other
Description��g�
Water -bearing zones:
1) From P:� Z4 To �-
2) From To
3) From To
Gravel pack well: dia.
Screen:
Slot'!
STATIC WATER LEVEL (all wells) //' ,,��
Static water level below land surface_lf.1 ft.
dia.
_ length from_
1
Da to `47
WELL TEST (production wells)
Drawdown_::��ft. after pumping__5j**4' hr.__—A_Qmin. at gpm
How measuredRecovery:—ft, after___3._hr. min.
0
LOG of FORMATIONS COMMENTS g
c
Driller
• J /
BOARD -OF HEALTH COPY
BOARD OF HEALTH
Town of North Andover,Mass .
Date i9/
rmit _
APPLICATION FOR WELL & PUMP PERMIT -
plica
tion.is hereby made for permit to drill a well (✓f• Application is
de to.install (V�a pump system.
_. Lot # • � /1•,�..
cation: Address
A
S n ✓e /,��,.���Address
Ener
n/ /�.,�a ✓Yl �T C
�.Q n,S Tel. o3-�
Addressy'-Soo�
�,� <,,,sT„('_
,11 Contractor--sf�`'>- � -
„• , oa ���s"�'�el
imp Contractor S i�,', s Sd-
7n� Addressg-% 1%r n! L �
;LL CONTRACTOR (To be completed at time of pump test)
W e 11 used for-_____T-
/pe of Well
Size of. Casing
iameter of Well r ,
g�
` Depth casing into Bed Rock /
C)apth V9 Bed Rock
Date. of Tcsting � g
as Seal Tested? Yes () No (-) -
3QO Well Ended in W.ha.t- Material �6,�.,'� -
� p t h •o-f �'J-e-']-�-- -•
' Delivers s_Gals.Per Min. for 4 hours
Ppth to Water-
feet feet after pumpin_hours
rawdown �6O' atGPM
g
ate of Completion c We ontractor
2igna
• ;**-A
�cXx�:c:ti:.....n..,...•.,.,.x:. .,,..,..,cam; .,,.'..i•nstal.].ati.on).
'UMP INSTALLER (To be- fill cd i.n be f o.rc
ff Pump Type Used 5j
;ize & Name Pump
—� • , 30 Carr l �011� --
GPM Size of 'Tank__
later Pump Delivers K1
Galvani �cd ( )°} Plastic
'ipe Material Used in Well: Cast Iron (_) -
Jell Pit ( ) or Pitless.Adapter
protect pipe? Yes (_) NO(N rype or Name Well Seal Cc O
•las sleeve used to
)ate is 9�n aG l.'.�.n,. V;:D�rrr
t�►r�`c1M►44�t��r�'c��r�4►����'r�M�'r���'�i4�M��r�4�r�C�'t�4�4�r�4�4►4�Y�t�4�4►'tti4�Y►4�'tti'��<�'r�'t ,'::'c:: ;,-ictictic, ,r','r•:;:
Date Water analysis report 'submitted to Board of }iea1th
Date release given tD owner of record & lilclg. Insp
}-{ealth Inspector
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FORM U - LOT REMEASE 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 this section*****ff*GG***********
APPLICANT: SS /A1 A () eQ . 11 G Phone
v
LOCATION: Assessor's Map Number ZJQ />f Parcel
Subdivision
/ULot (s) �.
Street Fill P K) LA M (2 a e -f - St. Number
************************Official use Only************************
RECO103MAIONS OF TOWN AGENTS:
Date Approved �� v
Conservation Administrator Date Rejected
Comments
VAT -01 -Am- Arl,
Town Planner
i
Comments
.JJZ�O.P.
Health Agent
Date Approved 2
Date Rejected
Date Approved
Date Rejected
Comments _iF 4VEL4 A&)7- ,�TY��9� - 0 K Td T/E /A/
LtJ�TC� TJ�`ii' LtJ/�TEiP � ��-
Public Works - sewer/water connections 007�pwQ✓ 6+..1Cv�
- driveway permit e+ rel yap (,CL /�i , �,�� /, ���`0
Fire Department
Received by Building Inspector Date
NUMBER FEE
13L3 THE COMMONWEALTH OF MASSACHUSETTS $25.00
TOWN NORTH ANDOVER
..................... of.............................................................................
This is to Certify that ........ Skillings & Sons
-----------------------------------------------------------
NAME
................... 2.4P ... Proctor... Hill-..Roadl___Hollis, N.H. 03049
ADDRESS
IS HEREBY GRANTED A LICENSE
For --------- Well._Drilling-... Permit ... m..Lat... 5.AA...k draUM ... oad--------------------------------
This license is granted in conformity with the Statutes and ordinances relating thereto, and
expires ... ---December 31, 1992 unless sooner suap I e?I\
�,. __r.,_�. -:Y ...:............ .`............--•---................
December 11 2 "......
:.---------------
.FORM 433 HOBBS & WARREN. INC.
DATE // 9 z
rec. ive •
Sheet of
BOARD OF HEALTH
TOWN OF NORTH ANDOVER
APPLICANT SO B A! Y_ _->; r',:. ASSESSOR'S MAP
ADDRESS
ENGINEER 5co-g GiCEs
PARCEL #
LOT # ;
STREET 57 .
ADDRESS ,SC6DE�� /�� A r�c0 ]Rd, N. A -
PLAN DATE 101/919z REVISION DATE
CONDITIONS OF APPROVAL:
APPROVED /Z I3%QZ
DISAPPROVED L---
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P + T pla PgR ry 4IN G
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3) `D -BOX SPE6/F16,IriONS /L1155iN6
4) --RE5erg V� /5 No0/'7 IV
-5) 1UETL,9NDS � 15GGA/MEQ M/55/AJG C Al,
SUBSURFACE
DISPOSAL DESIGN REVIEW
FEE O
PERMIT
# �- DATE
RECEIVED
APPLICANT SO B A! Y_ _->; r',:. ASSESSOR'S MAP
ADDRESS
ENGINEER 5co-g GiCEs
PARCEL #
LOT # ;
STREET 57 .
ADDRESS ,SC6DE�� /�� A r�c0 ]Rd, N. A -
PLAN DATE 101/919z REVISION DATE
CONDITIONS OF APPROVAL:
APPROVED /Z I3%QZ
DISAPPROVED L---
'k/ � l� �t � esus E � i�bu� his rANc �S d /-� 55 D 5 r -v ��uG�� ��v� C/�'• %� , l . Qr,j cL t h
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4) --RE5erg V� /5 No0/'7 IV
-5) 1UETL,9NDS � 15GGA/MEQ M/55/AJG C Al,
DATE /�
Sheet of
BOARD OF HEALTH
TOWN OF NORTH ANDOVER
SUBSURFACE DISPOSAL DESIGN REVIEW
FEES D PERMIT # DATE RECEIVED �3 9
APPLICANT B08 ASSESSOR'S MAP
ADDRESS
PARCEL #
LOT #
STREET',4,�/LUs'�y1 5T,
ENGINEER _ j Com 6166-6
ADDRESS J-6 /72&AWCO
PLAN DATE _l0 �/4�9Z REVISION DATE
CONDITIONS OF APPROVAL:
APPROVED l Z/ 3hZ,
DISAPPROVED L-�
D/-- 5SDS I`Z� �GUGGG�/!/�
'�7) PZ&,19SC" "i2ENC11�5 61V 56cr'io�
3) -D- BoX SPEC/FiC/97'/ON5 M/3s/1v6
,3J (UETL/�Nfl 5 U �SGLA/ME.� /�lSS//1/6 (�/, 6/6- OZ ��
e
PLAN REVIEW CHECKLIST
ADDRESSr9i9 ,9/T/j/U/t-J ENGINEER sc,p 7T (gl Z &"S
GENERAL
3 COPIES L/ STAMPy
CONTOURS t/ PROFILE
PERC INFO ELEVATIONS
WETLANDS
FDN DRAIN c/
SEPTIC TANK
WATERSHED?A/O
SCH40 [.,-'
LOCUS. NORTH ARROW SCALE U
SECTIONS BENCHMARK Z--- SOIL &
WETS. DISCLAIMER WELLS &
DRIVEWAY 4,-," .(Elev) WATER LINE
TESTS CURRENT?
MIN 1500G. �j .17 INVERT DROP !/
-D knllV
25' TO..CR MANHOLE TO GRADE
D -BOX
SIZE
# LINES Z
GARB. GRINDER v (+200% EDF)
ELEV GW
FIRST 2' LEVEL STATEMENT
INLETA V2, - OUTLET Z4Z. 3 = / (2" OR .17 FT) TEE REQ' D?
LEACHING
RESERVE AREA 4' FROM PRIMARY?� 100' TO WETLANDS c/ 2% SLOPE
100' TO WELLS 35' TO FND & INTRCPTR DRAINS 4' TO S.H.GW i/
325' TO SURFACE H2O SUPP L� 4' PERM. SOIL BELOW FACILITY
MIN 12" COVER FILL?(f (25' if above natural elev; 101if below)
BREAKOUT MET?
TRENCHES
MIN 660 gpd(/ . SLOPE (min .005 or 6"/1001) � >3' COVER? - VENT V
SIDEWALL.DIST.,2X EFF. W OR D (MIN 61)L,-- IS RESERVE BETWEEN
TRENCHES?e--' IN FILL? (,-- MUST BE 10' MIN. c--' 4" PEA STONE? L,--"
BOT 44A X LDNG ,3/ Z + SIDE aA 6 X LDNG 3G-5"= TOT 6 %l ,;-nloO
(L x W x #) (G/ft2) (DxLx2x#)
/. S Noce rQ. �e PrN- j5tc774N
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Town of North Andover, Massachusetts Form No. 1
BOARD OF HEALTH
19
A
APPLICATION FOR SITE TESTING/INSPECTION
Applicant , _ •:k ,. �.�;
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.
Town of North Andover, Massachusetts Form No. z
NORTIy BOARD OF HEALTH
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"• -=-- ,F` DESIGN APPROVAL FOR
C"„SEt� SOIL ABSORPTION SEWAGE DISPOSAL SYSTEM
Applicant" M t "GA'4_� Test No.
Site Locaon d0./L�►'�--��it�
� ference Plans and Specs. �o 0
Permission is granted for an individual soil absorption sewage disposal system to be installed
in accordance with regulations of Board of Health.
Fee
CHAIRMAN, BOARD OF HEALTH
OF HEALTH
Site System Permit No. Jt-�
2¢3
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LAW
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