HomeMy WebLinkAboutMiscellaneous - 31 LACY STREET 4/30/2018 31 LACY STREET
G 210/105./D/-01140000.0
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N0 2 4 5 0 Date........- Vii... ...........
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TOWN OF NORTH ANDOVER
0 A
PERMIT FOR WIRING
�,SSACHUSEt
7
This certifies that .... '.
has permission to perform✓: .......
wiring in the building of . � . �-'
at..`.y.......I.........I.......-;..Zl ........................�,.!......... ,North Andover,Mass.
Fee ... ......r Lic.No. ............. r...�.... r:.r..........................
._
ELECTRICAC INSPECTOR
Check #
WHITE:Applicant CANARY: Building Dept. PINK:Treasurer
O;
_ The Commonwealth of Massachusetts ;ice Use Only
e.
Permit b.
�v
.Department of Public Safety
Oeeapancl•S Fee Occked
BOARD OF FIRE PREVENTION REGULATIONS S27 CMR 7200 3/9.0
(leave blank)
i
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
Alt work to be performed In accordance with the Mawehusetu Electrical Code, 527 CMR 12:00
(PLEASE PRINT III INK OR TYPE ALL INI;ORHATION) Date
City or Tocm of To the Inspector of Wires:
The undersigned applies for a permit to perform the electrical work described beloJ.
Location (Street & Number) Al laQu Kb, V'l
Owner or Tenant
OI
Owner's Address
Is this permit in conjunction with a building permit: Yes No ❑ (Check Appropriate Box)
Purpose of Building Utility Authorization NO.
Existing Service Amps / Volts Overhead ❑ Undgrd❑ Vo. of Meters
flew S'i• ice Amps / Volts' Overhead ❑ Undgrd ❑ 1io. o° Y,-ter,
Number of Feeders and Ampacity
-----------
Location and Nature of Proposed Electrical Work Am I '
P
i
No. of Lighting Outlets No. of Hot Tubs No. of Trans:o-m>_rs Total
KVA
t No. of Lighting Fixtures Swimming Pool Above In-
grnd. ❑ grnd, ❑ Generators KVA
No. of Receptacle Outlets No. of Oil Burners No. of Emergency Lighting
Battery Units
No. of Switch Outlets No. of Gas Burners FIRE ALAR:`IS 1io. of Zones
No. of Ranges Total No, of Detection and
g No. of Air Cond. tons Initiating Devices
Disposals No. of Heat Total Total
No. of pum sTons K,' No. of Sounding Devices
No. of Dishwashers Space/Area Beating K4 No. of Self Contained
Detection/So;:nding Devices
No. of Dryers Heating Devices K� Local 11conncipal ectio ❑Other
Con-
No. of Water Heaters ),Il No, of No. of Low Voltage
Si ns Ballasts Wiring
r� No. Hydro 2lassage Tubs No. of Motors Total Hp
t
OTIC-R:
INSURANCE COVERAGE: Pursuant to the requirements of Massachusetts General Laws
I have a current Liability Insurance Policy including Completed Operations Covera_;e e: its substantial
equivalent. YES❑ NO ❑ I have submitted valid proof of sare to this office. Y%S❑ NO ElIf you hav7BOND
ked YES, please indicate the type of coverage by checking the ap?:opriate bo':.
It<SURANCE [:] OTHER ❑ (Please Specify) U �,11ce
Estir..ated Value of El(e�c,-t�rriical Wori•. S U Expiration Date)
/��
1lork to Start Inspection Date Requested:
Signed unlties of perjury:
Vi CL�
1.1censee _Sigr.aLure
Q n �l /q n 0-. -UA ti0.
address I \ Moo, 230. t_.o utj"
iS
01
Oi'IN-EMS INSURLNCE WAIVER: I am aus:• ..
e that the Licensee does not have the insurs __ overage or its sub'
stantial equivalent as required by Nassachusctts General Ln- s, and that ny signa:u:c On this pe it C
application waives this requirement. O-w1jer Agent (Please check one) � S• Q C/Jl
L.z�cation
l
p, Date
NORTp TOWN OF NORTH ANDOVER
Oft . o , 1'1•
♦ i
Certificate of Occupancy $
r
9
cMBuilding/Frame/Frame Permit Fee $ - �
ss� usE
Foundation Permit Fee $
Other Permit Fee $
TOTAL
Fheck #
.� J n - c �_
Building Inspector,
I `
TOWN OF NORTH ANDOVER
BUILDING DEPARTMENT
APPLICATION TO CONSTRUCT REPAIR RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING
This Sectio»#br OtTil W-Use Oil
BUILDING PERMIT NUMBER: DATE ISSUED: '
SIGNATURE: / • Vim' ,�
Building Commissioner/1for of Buildings Date z
SECTION I-SITE INFORMATION
1.1 Property Address:
1.2 Assessors Map and Parcel Number: O
00.
Q 0, �a D015,
0 Map Number arcel Numb 93
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sf) Frontage ti)
1.6 BUILDING SETBACKS ft
Front Yard Side Yard Rear Yard
Required Provide Required Provided Required Provided
1.7 Waler Supply M.G.L.C.-10.§34) 1.3. Flood Zone Information: 1.8 Sewerage Disposal System:
Public 7 Private p Zone Outside Flood Zone 0 Municipal C On Site Disposal System
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT M
2.1 Owner of Record
�' OHO + Mbui�� d' l ay �/ 3/ 4�9(Y 67. iva • hu,�Out--P,
Name(Print) Address for Service
✓-�
79V- 23V6
Signature elephone Q
2.2 Owner oC Record: O
Name Print Address for Service: O
Z
M
Signature Telephone
SECTION 3-CONSTRUCTION SERVICES
3.1 Licensed Construction Supervisor: Not Applicable ❑
Licensed Construction Supervisor: O
License Number
Address D
p Expiration Date
Signature Telephone r
3.2 Registered Home Improvement Contractor Not Applicable ❑ v
Company Name I '1
Registration Number r
Address r
Expiration Date nz
Signature Telephone Y'
s
SECTION 4-WORKERS COMPENSATION(M.G.L C 152 § 25c(6)
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result
in the denial of the issuance of the building permit.
Signed affidavit Attached Yes.......0 No.......❑
SECTION 5 Description of Proposed Work check all applicable)
New Construction ❑ Existing Building ❑ Repair(s) 0 Alterations(s) 0 Addition 0
Accessory Bldg. ❑ Demolition 0 Other 0 Specify
Brief Description of Proposed Work:
QL} ' ren)nd Wooue 4rouna DOOl
SECTION 6-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollar)to be `" OFFICIAL USE ONLY
Completed by permit applicant
1. Building (a) Building Permit Fee
Multiplier
2 Electrical (b) Estimated Total Cost of
Construction
3 Plumbing Building Permit fee(a) X (b)
4 Mechanical HVAC
5 Fire Protection
6 Total (1+2+3+4+5) 03 Check Number
SECTION 7a OWNER AUTHORIZATI N TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, M Du I P, P-�/6 LE as Owner/Authorized Agent of subject property
Hereby authorize to act on
My behalt; 'n all matters relative to w rk authorized by this building permit application.
kagm
Signature of xner Date
SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION
I, as Owner/Authorized Agent of subject
property
Hereby declare that the statements and information on the foregoing application are true and accurate,to the best of my knowledge
and belief
Print Name
Signature of Owner/A ent Date
NO. OF STORIES SIZE
BASEMENT OR SLAB
SIZE OF FLOOR TIMBERS 1 2ND 3RD
SPAN
DIMENSIONS OF SILLS
DINIENSIONS OF POSTS
DIMENSIONS OF GIRDERS
HEIGHT OF FOUNDATION THICKNESS
SIZE OF FOOTING X
MATERIAL OF CHIIvv1NEY
IS BUILDING ON SOLID OR FILLED LAND
IS BUILDING CONNECTED TO NATURAL GAS LINE
-� FORM - U - LOT RELEASE FORM
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 M0,016)9 IT LL-_)9A y PHONE 7 aw-L
ASSESSORS IAP NUMBER 105 LOT NUMBER ca
SUBDIVISION LOT NUMBER
STREET '�r/Cf 6T• STREET NUMBER 3
OFFICIAL USE ONLY o [ 00 Ll
...........................■.■■.■■.■■■■■.■■..■..■■...■r.■■ ....... ........
RECONfNfENDATIONS OF TOWN AGENTS
1 l,o,-N Vh1 ZJ1r.S S X- DATE APPROVED
CONSERVATION ADMINISTRATOR
DATE REJECTED
COMMENTS
f p� pool O��?4'0'�
v
DATE APPROVED
TOWN PLANNER
DATE REJECTED
COMMENTS
DA'IE APPROVED
FOOD&SP S3EALTH DATE REJECTED
DATE APPROVED �ro ZL?
CCTOR-HEALTH
DATE REJECTED
CONOAENTS /Iii 21r.._42 r`t.` lD �e ,r+- k
PUBLIC WORKS-SEWER/WATER CONNECTIONS.
DRIVEWAY PERMIT
DATE APPROVED
FIRE DEPARTMENT
DATE REJECTED
COMMENTS
RECEIVED BY BUILDING INSPECTOR DATE
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AKJOI 0bMFL1---.3 W17 4 T-He 2oNiLJ4 3,--r a4eI--
74-E T�Dwu of uo 4Q.C�- ' GEOTECHNICAL CONSULTANTS
Y�2 , eT��2 e�en�r ar T a r�v� OF MASSACHUSETTS, INC.
r4 cZt�G�A PL.j#I IV 799 Turnpike Street
NORTH ANDOVER, MASSACHUSETTS 01845
2
NORTH
Town of over
No.
o -_ �A E ori dower, Mass.,
6 �► a o
I� COHICHEWICK
ADP '��
RATED
S H BOARD OF HEALTH
PERMIT T D Food/Kitchen
Septic System
BUILDING INSPECTOR
THIS CERTIFIES THAT. ........N..... ,MO .I.CA.......... .... .of I'+ ,/
Foundation
A
has permission to erect...a.. ...................... buildings on .....�..1............... .C...........s .'....... ........... Rough
to be occupied as....� ...... VVt......6 V y�......�M.'......� ..... /jU r4 t Chimney
provided that the person accepting this permit shall in every respect conform to the terms of the application on file in Final
this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteraon and Construction of
'
Buildings in the Town of North Andover. �I1A , D ,' S's INSPECTOR
ir VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough
a
MAI%) 614 Final
' PERMIT EXPIRES IN 6 MONTHS
O b�� 4 A��� ELECTRICAL INSPECTOR
UNLESS CONSTRUCTION T T�
pow w► rt b Rough
wal{ �P��ty .............. ............................................. ................ Service
k1 64 F. U .
BUILDING INSPECTOR Final
Occupancy Permit Required to Occupy Building GAS INSPECTOR
Rough
Display in a Conspicuous Place on the Premises — Do Not Remove Final
No Lathing or Dry Wall To Be Done FIRE DEPARTMENT
Until Inspected and Approved by the Building Inspector. Burner
Street No.
SEE REVERSE SIDE smoke Det.
60
50
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AQo (fir-r�Lreg w1rH T+-rE ZoN�I-le, 9�r- �4e�
4urs��M�N%� o� Ta00 OF A-oe-ny 4(=t::,- GEOTECHNICAL CONSULTANTS
�ue7l�4E2 c;=en>%r T'-IAT -'+4-- -a-r3ot/E OF MASSACHUSETTS, INC.
1-l-m-IG-1 t� J�Jr�''- C.X.47�T> �p.1 A FZr�aA� 7'L.�1l N 799 Turnpike Street
Jl NORTH ANDOVER, MASSACHUSETTS 01845
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FORM - U - LOT RELEASE FORM
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.
@..............A.n...........................................................■
APPLICANT PHONE � 6
ASSESSORS MAP NUMBER LOT NUMBER C
SUBDIVISION LOT NUMBER
STREET f/cf STREET NUMBER 3 /
................. .................names..9....2...0........a.....
OFFICIAL USE 01VLY �O L �? �9
12 9 9 0.2......0.9 xi6m 2 9 0..2 9 2••0 9.0...0..0......a.a 0..0.....■ .....a. .......■
RECONOvIENIDATIONS OF TOWN AGENTS
I... ..._................................................a....../... 0209......
t, DATE APPROVED ` rO 0"
CONSERVATION ADMINISTRATOR
DATE REJECTED
COMMENTS / IV ;D� Pool Oj i,aQ
DA'I�L• APPROVED
TOWN PLANNER
DATE REJECTED
COMMENTS
DATE APPROVED
FOOD INSP TOR- TH DATE REJECTED
DATE APPROVED Z>n
C ECTOR-HEALTH
4—a
- DATE REJECTED
COMMENTS /Iii 2_7c,^-a r`t.,,_ ID r7'�e
PUBLIC WORKS-SEWER/WATER CONNECTIONS.
DRIVEWAY PERMIT
DATE APPROVED
FIRE DEPARTMENT
DATE REJECTED
COMMENTS
RECEIVED BY BUILDING INSPECTOR DATE
Lj 4-5
4$, l !
•, 61,E
D�Si6,C1 .36 'x z-sC
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F S.
JAS
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t 44E253-r Tsar 7--YE LDl1-rg O� T�/g
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duo mr-�Lr wr7W T-Hfr 2oN1uG sir
S Tzt)&UX4 cF A-4=le7l,;� •�- GEOTECHNICAL CONSULTANTS
7-14,a-r rl e 4.r3c,V-= OF MASSACHUSETTS, INC.
F2�o, p
�j L�#I N 799 Turnpike Street
NORTH ANDOVER, MASSACHUSETTS 01845
d/�� 635- 48or�
Board of Health = SEPTIC S75TEK
North An ver Haas. . J
INSULLATICK CHBICK LI OTLIC
's !
pVED DATE BISA-PPROM tXCAVATINOA FAIL
easpns!
TO T4W?14c,5 !,U Z 5 ,S Q1
;i
;I � .
CK
1. Distance Tot
¢a2, a. Wetlands
U b. Drains
c.. Well
` 2. Water Line Location
3• No PPC Pipe
}�. Septic Tank
a. _Tees -_Length & To Clean Oat Covers.
b. Cement Pipe .to Tank •- On Both Sides of Tank
,. 5. Distribution Boa
a. Covers & Box - No Cracks
b. All bines Flowing Equal Amounts
c. No Back Flow
;• 6. - Leach Field or Trench
a. Dimensions
b. Stone Depth
c: Capped 'hds
d. Clean Double'Washed- Stone' -
! 7• Leach Pits
a. Dimensions
'r b. Stone Depth
c. Splash Pads
d. Tees
e. Cemmt Pipe to Pit - Both Sides
f. Clean Double Washed Stone
8. No Garbage Disposal
-Final Graffi Inspection
10. Barricading Covered System
f ll. As Built Submitted
a. Lot Location -
b. Dimensions of System
c. Location with Regard-to Pere Test
f d. El.ervations
'` t e; Water Table
board of Health
SUBSURFACE DISPOSAL DESIGN CHECK LIST
t — LOT
APPROM DATE - DISAPPROM DATE
Provided, =y/{� ��//� ,•mom ,M.�.. Reasons
j/
Title V FAIL, �
Reg X2.5
e.submitted plan must show as a minimum=
a) the lot to be served-area,dimensions lot #,abutters
location and log deep observation hoes-distance to ties
cation and results percolation tests-distance to ties
sign calculations & calculations shauing rec_uired leaching area
location and dimensions of system-including reserve area
existing snd proposed contours
location any vot areas within 1001 of sew-age disposal system or
disclaimer-check wetlands gypping
surface and subsurface drains vithin 100' of se-.,-age disposal
system or disclaimer mr
• ) location any drainage easements thin 100' of stege disposal
system or disela me-r-Planning Board files
(3) know sources of vater simply within 200' of sew-_ge diSuo� a -
stem or disclaimer
ation-of-any proposed -,-el1 to serer lot-100' from leaching facil
cation of water lines on property-101 from leaching S cili y —
location of benchmark _
- n arivekaya -
o) garbage disposals _
{ 1 nn PVC to be used in construction
q profile of system-elevations of basement, plumb, pipe, septic tank,
distribution box-inlets and (ntlets, distribution field piping and
Otter elevations
Cr)- maximam ground s,ater elevation in area se-6-age disposal ssst.em
plan rust be prepared by a .Professional Engineer or other
professional authorized by -law to prepare sueb plans -
pig 6 SeictTanks
a eaDEcities-15o%. of flog, meter table, tees, depth of tees,
access, pu,--
(b) cleanout
(c) 10' from cellar ill or in,-round. s -ng Pool
%(d) 251- from subsurface drains -
Reg 10.2 Distribution Foxes
(a) slope greater than 0.08
Reg 10.4 I b)
-
Subsurface Design Check List Page 2
FAIL Cg
Leaching Pits
Leaching pits are preferred where the installation is possible
Reg 11.2 a) calculations of leaching area-ninimum 500 eq ft
11.4 b) spacing +
11.10 c) surface drainage%
11.11 d) cover i teriai
e) 213VAP splash pad
f) �Wee at elbow
g) no bends in pipe Brom d-box to pipe
Leaching Fields
Reg 1�.1 a) no gr"ter than 20 minutes/inch
)' area-mi nirum 900 sq ft
15.4 G)- construction of field
1-5.8 ,l d) surface drainage 2 %
3.$ e) 201 from cellar van or ingroumd swinal ng pool
Leachina Tranches
Reg 14.x. a) c—a Gula ons of leaching area-min 5b0 sq ft
14.3 b) spacing-4; ft aria 6 ft with reserve between,
14.4 c) dimensions
74.6 d) construction
14.7 e) s ane
3.4.10 f); surface drainage 2%
Do Eat?l Slope
-a) slope p x = to be s`ho�ai)
b) y/x % 150 = (to be shown) _
Puns -
Reg 9.1 a) appal
9.6 b) and by power
Andover, Mass. Street No Got, (,,h.G.Y t F-c>2t ST Lot No
3ubdiv. Pland Owner
estigator 64sy. Observer
SOIL PROFILE DATES
i lAl.ev 2.Elev 3.Elev 4.Elev
(o 1 l erl
0 a` _ 0 G' 0 0
T{ S T S Ties Pits est
2 2 2 2
3 3 3 3
KE4 MEO - {
-
4 4 4- 4
5 5 5 5
S 6 6 6
'SLOES -�
7 510fS ,l � 7
- CAV 7 '
3 8 8 g
i.oi to , to 10
Benchmark Location
R
Elevation Datum 1
PERCO TION TESTS
DATES 11 ,Vq 03 t\ 2Z v
Pit Number 1 3 4
Start Saturation (o UL- v V1
Soak-Minutes
Start e
Drop of 3"-Time
Drop of 6"-Time
M6ms-Ist 3" drop
Mans.2nd " Dropv
Percolation
® L
c
40+
/ov
P
G.f3
Town of North And-over,Mass . p
Permit # 7�/ Date -
APPLICATION
�_ —190_7
APPLICATION FOR WELL & PUMP PERMIT
Application is heteby made for permit to drill a well ( ) . Application is
made to install (_) a pump system'. -
Location: Address Laren .--------_---___--- . .Lot #• 4__ - - . .
41
Owneryy SCP,If��U'ei2 Address— 'f77 flue S7' =- Tel
Well Contractor , Oj Address ? Z9 ofN(�4i1r 4U.(�Telk° �FZ3?i
Pump Contractor �`� -Address -/ 2L � Tel : 23 2
WELL CONTRACTOR (To be completed at time of pump test )
Type of We11_--7 ---Well used for
Diameter of Well y Size of Casing
Depth c Bed Rock �j Depth casing into Bed Rock_
Was Seal Tested? Yes ( No (_) Date of Testing___!%L-Q LJ�
Depth of Well _ �Up -__--- ---1Jell Ended in 1•Jhat Material �jy,,
--- -
Depth to 1%later_ � -- -_ i l el ivers_ (O _Ca l s . Per Min . for 4 h._--urs
Drawdown U O feet after pumping hours at (o GPM
Date of Completion 47k �9fs'�f
Signat=ure ell Contractor
JJ-_._-_L�.,..r"1!,J.J.J.-LJ,J._t-_t.J,J,._L J _1 ..,..t-�-�n i.-•- ii ii n�ri i."_n _�_ iL-
n
PUMP INSTALLER (To be filled-in before installation)
Size & P,;;iip Type Used �l�l3irlp.2Si4t,2
Water Pump Delivers_- 7-_GPM Size of Tank
Pipe Material Used in Well : -Cast Iron ( -) Galvanized ( ) Plastic
1,Jell Pit (_) or Pitless- Adapter (k')
Was sleeve used ,to protect pipe? .Yes (-) NO Type or PZame (dell Seal -
Date
i
" 'rl'Si
Date Water analysis report submitted to Board of l?ea]. th
Date release given tD owner of record & Bldg . Ii sp
?ea ]_th Inspector
Pumps
a Submersible
WELL & PUMP CO. o let
9� 9 RT.28 WIN DHAM, N.H.03087 o Centrifugal
e Cellar
�OOR S [603]898-4232 0[617J 887-5888 o Sewage
Tanks
Filters
o Softener
o Iron
o Charcoal
£a&R CONST TEL�NO. o Neutralizer
47.7 ANDOVER ST 686-3653
NO ANDOVER MA 01045 o Cartridge
Water Testing
Pump Parts
• LOT NUMBER OR SAMPLE LOCATIONS LOT #2 Motor Controls
Water Softener Salt
WATER TEST RESULTS 7 MAY 84 Resin Cleaner
• :tc••:�•:�•�¢•:�•�•�:&�ae•�•�:�•:��:�•ai•:�:�•:�::�:�•�:�:fi•:�r#:�:��:�•:�e•jr 3e-:�:�•�•:�di•:a•#�:�r:�i•fit•::�e••:�rai•:�t::�••3c•
• NART_?NES;=. 85, t0-50 REC C,TANDARL'}?
Rust & Stain Remover
IRON .2 (0—e3 REC STANDARD) Potassium
MANGANESL-. r_i (0—.05 REG ;STANDARD) Permanganate
HYDROGEN :-SULFIDE 0 (0—.01 REC STANDARD? Plastic Pipe & Fittings
Ph (ACIDITY) 7.5 (6.5-7.5 REC STANDARD) Lawn Watering
TURBIDITY 0 (0-20 REC STANDARD) Systems
CHLORIDES 10 (0—ISO REC STANDARD)
COLIFORM BACTERIA 0 ('0 REQUIRED STANDARD) Water Heaters
n a Solar
CHARGE FOR CHEMICAL & BACTERIA TEST ** $25,00 o Heat Pump
a �ifi�a�rma �a tr?r o Electric
ABOVE TESTS MEET REQUIRED STANDARD', AND BASED ON THTHESE, o Energy Saving
Wells
WATER IS SAFE FOR HOUSEHOLD USE AND HUMAN CONSUMPTION. a Drilled
THERE ARE OTHER LESS COMMON MINERALS NHIC•H CAN AFFECT
QUALITY OF WATER. a Driven
o Dug
o Gravel
Chemical Feeders
Tank Alarms &
Controls
*1 Hoist Service
Portable Pump Puller
N rt-rq fes - , (7 Emergency Service
lot
Goulds
Aermotor
Jacuzzi
Red Jacket
Fairbanks Morse
Wayne
Aquatron
Wel I-X-Trol
WELL DATABASE
ADDRESS: G
?.GL OF W 3 W`ELL DRIL-L R. �� !✓�'
W"ELLPERLvgT,T: WELL LOCATION: 16> 0 Ju�l
--- cR�rLL PERLti�i DA :-��1 a"1` DiTr�OFryEl L: rd ;
=E OF WELL: D b. DUG c. Lei _-
TYPEOE WA aEE`4RING ROCK_ J
WATT ANALYSIS:DA=-�` 7-- GH NVIANGA SE: Y N
EtTGaQN Y OTEECQNTAi�iINA1�ITS: Y N -
c -
f
VY-El-L DAT_ E.AE7
ADDRESS: ( c
AGE OF ; F=. WE r DRTT.r.F?t �
WELL PERI�'I T: ? WELL L O.CATION:
WELL.PERIYE DA Er: DEPTri OF WILL:
TYPE OF WELL: a. DRILLED b. U(a UNKNOWN
TYPE OF WATER BEARING ROCK:
WATER At`+Ai.YSIS DATE: 7 HIGH tiIANGANESE: Y N
HIGH IRON: Y N OTI= CONTAN�AINTS: Y N
Commonwealth of Massachusetts
North Andover, Massachusetts
Syste O ner& address: System Pumpinji Record
John O ary
31 Lacy treet
North Andover, MA
Location of system: Front yard JAN V 6 2005
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Date of Pumping: December 16,2004
Type of system: Septic Tank
Gallons Pumped: 1500 gallons
System pumped by: Service Pumping &Drain Co Inc
License #: BHP-2004-0004
Contents transferred to: Greater Lawrence Sanitary District
Date: December 16,2004 Pumping Technician:SD
This is PROPRIETARY and CONFIDENTIAL information that may be used only
by the Board of Health for regulatory purposes