HomeMy WebLinkAboutMiscellaneous - 464 Boxford Street 465 BOXFORD STREET e t
/ 210/105.,C-0049-0000.0 \
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465 BOXFORD STREET et
/ 210/105.C-0049-0000.0
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Token of'1-,�'brth-' Xndover,I-lass .
^errli-t r;— Date
APPLICATION FOR ,WE-L]", & P1111P PERMIT
Application is }hereby made for permit, to d'r. i_11. a well Application i s
M,Aee to r}gtall (—) a , pump :system-.
,�ocation: address �. • ° _ Lot
40
Owner —Address
f{
Y, ,.,_ ..roritrr�c C-or - _ d re s s�5�
-� -- _ - --—e Te 1.�-� �: 7 �
'ump Contractor t '��,�.��— dress y � XI' Yel +
ION1- ,CTOR (To be completed at time of p11111p test )
Type of O'Cll iG Jell used for___A�n� _.
D _ar.,et(.-r (- Well `( size of Casing-_
- - -
Denth of Tied Rock 2� Depth c.isi.ng into Ped Rock
`.,gas Seal- tested? Yes (� :. No. (—) Date of Testing _.
Denth of W'-4l_----- - -- _- - IJel.1 Ended in What 1.laterial �
Dept'1 to Titer D _ - Del_ivers_ �- —Gals . Per 11in . for 4 h_urs
Drawc1oT1^ feet after pumping—_ hours at - --_--GPM
Date of Corpletion
igi -ire t';ell C nt-racto_ _--
PUMP INSTAL LFQR �To be filled -in -before - installation)
Size S Nacrepump Pump Type Used
`nater Pump^elivers GPM Size of "Tank
-- --
Pipe llateriaiUsed in !':el_1 : Cast Iron ( . ) CaIv;;nized ( ) Pl.asti.c ( )
it or;,e- P 3--t-lci,34—A-F3-al)t e r
"as slee`ve..used to protect pipe?-_Yes ( ) NO(-- .) Type or Nave !-;ell Seal ---
;f-,% w i iL 9i::y�)fi 5.•lei-i- `i71f::`":':is', ' :. .. .. ., :. t,-..ll�,. ,. F,
Pate "atera naIysis report submitted to Board of Ilealth
Date releasegi_ven t_D ri( r .of ;record & 13,1 o.] Tnsp ---- ------ -----j`
Ile �lth Inspector
_ - =.1 -
Board of Health SEPTIC STSTEH .
North An4over2.Y_aae. '
INSTA'•I-ATICK CHECK LISP LOT' • 13a'
WU
�P
CUP DATE DI SUM AVATIC�t Ob FAIL
eat
J
DUw_--
FAIZ Og
c Z3'�r 1. Distance Tot
6 J a. Wetlands
b. Drains
c.. Well
2. Water Line Location
3. No PVC Pipe
4. Septic Tank
a. Tees -_Length do To Clean Out Covers
b. Cement Pipe to Tank - On Both Sides of Tank
5. Distribution Box
a. Covers & Box - No Cracks
b. All Lines Flowing Equal Amounts
C. No Back Flow
6. Leach Field or Trench
a. Dimensions
b. Stone Depth
c. Capped Ends
d. Clean Double Washed Stone
7. Leach Pits
a. Dimensions
b. Stone Depth
c. Splash Pads
d. Tees
e. Cart Pipe to Pit - Both Sides
f. Clean Double Washed Stone
8. No Garbage Disposal
9. Final Grading Inspection
10. Barricading Covered System
11. As Built Submitted
a. Lot Location
b. Dimensions of System
c. Location with Regard_to Pere Test
d. Elevations
e: Water Table
i
mrd of Health
4cie..Y. -Andover,Mass
sUBSORME DISPOSAL DESIGN CHECK LIST
- LOT
APPROVID DATE li' DISAPPROVED DATE_,_
Provided: 6A
Reasons:
AeU131oJ ov way .
Title V FAIL 09 -
Reg 2.5 The submitted plan must show as a minimum:
a) the lot to be served-area,dimensions lot # abutters
b location and log deep observation hoes-distance to ties
c location and results percolation tests-distance to ties
d design calculations & calculations showing required leaching area
(e) location and dimensions of system-including reserve area
f) existing and proposed contours
g) location any wet areas within 100' of sewage disposal system or
disclaimer-check wetlands mapping
(h) surface and subsurface drains within 100t of sewage disposal
system or disclaimer
(i) location any drainage easements within' 1001 of sewage disposal
system or disclaimer-Planning Hoard files
(3) knows sources of water supply within 2001 of sewage disposal a .
system or disclaimer
(k) location of arq proposed well to serve lot-1001 from leaching facility,
(1) location of water lines on property-101 from leaching facility
(m) location of benchmark
(n) driveways
-- (o) garbage disposals
(p) no PVC to be used in construction
(q) profile of system-elevations of basement, plumb, pipe, septic tank,
distribution box inlets and outlets, distribution field piping and
Other elevations
(r) maximam ground water elevation in area sewage disposal system
(s) plan must be prepared by a Professional Engineer or other
professional authorized by law to prepare such plans
Reg 6 Septic Tanks
(a) capacities-150;6 of flow, water table, tees, depth of tees,
access, pumping
(b) cleanout
(c) 101 from cellar wall or inground swimad.ng pool
(d) 251 from subsurface drains
Reg 10.2 Distribution Boxes
(a) slope greater than 0.08
—R-eg10.4 b) sump ---
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Address 0 Title of File Page of
Date File Open: Date file closed:
Doc Document/Action Title Date of Refer to other Purpose of Document/Action and notes:
action Document/ document/
Num. Action Department
1
Board of Appeals — Board of Health — Planniing Board _ Conservation Commission — Buil-ding Department �' i
North AAdovert Mass. Street No Lot NoPland Owner
Tnvc3tigator. Observer IfF�
SOIL PROFILE DATES
eV__ 0 2.Elev- 3-Flev 4.El-ev
r
0 O __
Ti-es to Test
Pits
2 2 2 2
4 4
V161,
Opt-
7. , 7
8 88
91 - 9 9 9
30 l0
10
Ir)c�tion
Yl c-v ati on Datum
ON P-" -i's
DATES
Pit N k 2 I 3 4
.-Start Satsration
OEI.- .iliiites
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Dr"o,p of 6_'_`-_TJ_mje
s dropDrop of �)"-Time
AVj is.Pnd
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Town of Andover
Massachusetts
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Board of Health
Permit No. - Date
APPLICATION FOR WELL WATER INSTALLATION PERMIT
Application is hereby made for a permit to drill ( ) or repair ( ) a well .
Application is also made to install ( ) major renovation ( ) or major
repair ( ) of pump system.
Location: Address Lot Number
Owner Address `
Well Contractor Address
Pump Contractcr Address .
WELL CONTRACTOR (To be filled in at time of pump test-),-
Type of Well Well Used For
Depth of Casing Size of Casing
Depth to Bed Rock Depth .of Casing into Bed Rock
Was Seal Tested? Yes ( ) No ( .) Date of Testing
Depth of Well Well .Ended in What Material
Depth to Water Delivers Gallons/per/Minute
Drawdown feet. after pumping four hours at GPM. Sketch map
. of well location with tie down lines on reverse side of this _form, and soil
strata. I understand that :I am also responsible for the eatiefactory per- Y
formance of the well pump.
Date of Completion
^/ Well Contractor's gnature
j PUMP INS:'ALLER (To be filled in before installation)
Size and Name of Pump. Type of Pump Used
Water Pump Delivers GPM Size of Tank
Pipe material used in Well : Cast Iron ( )
Depth of Pump
Well pit ( ) or Pitless adapter ( )
Was sleeve used to protect pipe? Yes ( ) No ( ) Type of Name of Well
Seal
Date_ y
1TK&P' I'hi9fal1pt0sVignature
Date water analysis report submitted to Board of Health
Date release was given to owner of record and Building Inspector
_T17_ _
lnv,s-� de `6 C/7 /V Or1-4 el'"Idve-r---
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7houtewdem ,eakratozcy, 9&c. '�
U -7A
66 LITTLETON RD. -WESTFORD, MA 01886617)69 95
t/Robert
Report Number: C-059-8858Report D�1to : ]-?ov 26 , 1.984
Client : Sam- 1 ak
ATTN: Mike McIntyre Pouliot , Owner
Merrimack Well & Pump Boxford Rd .
Tinker Rd. North Andover, MA
Merrimack, NH 03054
Sample Taken. by: Requester On: Nov 20, 1984
CERTIFICATE OF ANALYSIS
-------------------------
Test Parameter: Results :
UNITS Sample 1
Coliform Bacteria per 100cc 0
Soap(MBAS) mg/l NT
Lead mg/l less than .002
Acidity Value SU 6 . 1
Arsenic mg/l NT
Barium mg/l NT
Cadmium mg/l NT
Chromium mg/l NT
Color CPU NT
Flouride mg/l NT
Hardness mg/l NT
Iron mg/l 0.007
Manganese mg/l NT
Nitrates (as N) mg/l NT
Odor TON NT s.
Selenium mg/l NT
Turbidity NTU NT
Total Organic Carbon mg/l NT
NT = Not-Tested
The items listed above meet or exceed the EPA qua ty standards
for potable water.
Massachusetts State Certified
Microbiological Drinking Water Peter T. Thorstensen, for
Laboratory #33051 Thorstensen Laboratory, Inc.
WELL DATABASE
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ADDRESS:
AGE OF WELL: _ WEELL DR??LEER.-
WELL PE_R IT.T. - WELL L6CATION: 1
— 'ALL PERMT DAA: -=- DEPTH OF WELL:
-TYPE OF WELL: _ D o. D G c. L NiS i�iOW N
TYPE OF WA=HEi4RINCi.RO
WA=ANALYSIS DAZE SIGH 2NL,-�NGANTESE: Y
ffLGff IRON: Y OT=CONT.AlfTAL TS: Y
�r1%r-T T' DAT A-SE /
ADDRESS:
AGE OF WELL: W ELL DRILLER-
.7v=
RILLER.WELL PERIYIIT T. WELL LOCATION
WELL PER�rIITDATE: \ DEPTH OF WELL:
TY-PE OF WELL: a_. DRILLS b. DUG c. UMKNIOWN,
TYPE OF WATER BE. 'G ROCK: ^
WATER ANALYSIS DATE: HIGH MANGAi TESE: Y N
HIGH IRON: Y N OTHER CONTAIN2 ANTS: Y N
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