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HomeMy WebLinkAboutMiscellaneous - 940 GREAT POND ROAD 4/30/2018BOARD OF HEALTH 120 MAIN STREET NORTH ANDOVER, MASS. 01845 APPLICATION FOR ABANDONMENT OF SUBSURFACE DISPOSAL SYSTEM (SEPTIC SYSTEM) PURSUANT TO SECTION 310 CMR 15.354 OF THE STATE ENVIRONMENTAL CODE, TITLE V TEL. 682-6483 Exc23 This form must be submitted to the Board of Health no less than five (5) days prior to date of abandonment and be accompanied with a copy of the sewer connection permit. Name Phone Address lK.,/I Contractor hired for work: Name C� Ll e Phone c�► =2Z Address �L'I Date for scheduled abandonment Method of septic tank abandonment (check one). ( ) removal ( ) sandfill ( ) crush ( ) other (describe below) Other PLEASE DO NOT WRITE IN THE SPACE BELOW FOR HEALTH AGENT'S USE ONLY Inspecting Agent Comments Date v N - R 1140 E* APPLICATION FOR SEWER SERVICE CONNECTION North Andover, Mass. �- ` 19�� Application by the undersigned is hereby made to connect with the town sewer main in `%✓�� `r" oz1� Street, subject to the rules and regulations of the Division of Public Works. The premises are known as No. Street or subdivision lot no. Owner (ci"/?) oc Contractor 0 CeA'1sC,er/l� 7-1,9 h/ Address Address i I/ icdnt's Si PERMIT TO CONNECT WITH SEWER MAIN The Division of Public Works hereby grants permission to to make a connection with the sewer main at subject to the rules and regulations of the Division of Public Works.. Inspected by Date T See back for rules and regulations Street Division of Public Works .11 ILL nl t Commonwealth of Massachusetts Massachusetts System Pumping Record System Owner System Location Co vc, �.� � DC7 j v Date of Pumping: q Quantity Pumped: gallons Cgas_ nool: No Yes Septic Tank: No ❑ Yes AApe- System Pumped by: 64&d" 4504m ,d License # Contents transferrred to : Greater Lawrence Sanitary District Date: Inspector: Town of North: Andover Massachusetts Board of Health Permit No, 1Sh Data 1n/l9/92 Application is hereby made or a perwi�rotRtoEdriLL �D P�orPrepiTr () a well, is also made to install () major renovation Application () or major repair () of pump system, Location; Address 940 Great Pond Road - Lot Nu►b e r Owner I. Hefni Same Address _ 682-1900 We 11 Contractor Avel lino Well & Pump Address 244A Haven St: Reading T Pump Contractor Same ele hone # 617-944-5454 Address Same Telephone # WELL CONTRACt'OR (To be filled in 'at tine of puAp test) TYPO of Me11'Artesian - Well Used For Trriaa ion Diueter of Well -- Size of Cuing -, Depth of Bed Rock 12 , D+pth of Casing into Bed Rock 9 Was Seal Tested? Yes (X) No () Date of Testing 10/12/92 Depth of Well _909, Well Ended in What Material Bedrock Depth to .Water2n Delivers 10 Gallons/per/Minute � Drawdown after location with down lines on�revirs,00rs at 5 CPM, Sketch as of well f this:' ora, - Date"of Completion 10/12/9 PIMP INSTALLER '(To be filled in before installs ion 1 Cont act ' nature Size.and Name of Put 1 hp 10 qpm Jacuzzi Type of Pump Used Submersible Water Pump Delivers _10 - GPM 'Size of Tank Well Rite 120 Pipe anterial wed in Well; Cut, Iron O Galvanized Plutic ( ) Well' pit () or Pitless adapter ) Was sleeve wed to protect pipe! Yes () No Typ or Naar o Date —1011 1 H and Submersible /12/92 _ p Instal a snature Data water analysis report submitted to Board of Health Data cele u e w u given to owner of record and Building Inspector Health Inspector a` ti 10epartment of Environmental Managernent/Division ., WELL COMPLETION rces WELL LOCATION MIC DESCRIPTION Address 940 Great pond Rd N S/j,/'.��)W o1 !r lcrrcrel City/Town Ng . AIndnver �GRFRf PON4 b Well owner I. H e f n i (road) Address 940 Great Pond Rd N S E W of Non d a V e (nil. in,Tenths) (circle) intersect. w/ Board of Health permit obtained: yes U no ❑ (road) WELL USE WELL DATA Domestic ❑ Public ❑ Industrial ❑ Total well depth 505 ft. Monitoring ❑ Othet? r"ri jAti n epth to bedrock 12 ft, Method drilled Rotary Water -bearing tock/unconsolidated material: Uatedrilled � /�� �` Description50ft Green Rezk Water -bearing zones: CASING t).From 220 To 260 Type Steel Length�_ft. Dia(.I.D.) 6 in. 3) From To 31 From To Length into bedrock ft. Gravel pack well: dia. Protective well seal: Screen: dia. Grout.❑ Other Drivieshn-e Slog length from_to STATIC WATER LEVEL (all wells) „1 Static water level below land surface? _Yt. Date�� WELL TEST (production wells) Drawdown 505 ft. after pumping hr. 30 min. at, 5 gPtn HowMeasuredfr rig _Recovery ft. after—hr.—min. air LOG of FORMATIONS COMMENTS; Materials From To o. o t hoca-- H Driller LL-gh n 'm 6k i sSi r•k' Firm; • ` AWP CGNTRACTQRS`. Address 's4*k—Ka V an St City/Town R ®o t 4 . n`'n Supeing Driller Reg.#Q . __— 'r I - BOARD OF HEALTH COPY a Department of Environmental Management/Division of Water Resourc WELL COMPLETION REPz/ WELL LOCATION ION Address 940 Great Pond Rd 1,1 do N S( DEW of I&r )circle) City/Town No. Andover ���� Well owner I. H e f n i (road) Address @40 Arpat—Pond Rd N S E W of N o . Andover (ml. in tenths) (circle) Board of Health permit obtained: yesno ❑ intersect. w/ !road! WELL USE WELL DATA Domestic ❑ Public ❑ Industrial ❑ Total well depth 509 ft. Monitoring ❑ other irri,lplati ft7ppth to bedrock 8 ft, Method drilled rotary Water -bearing iocklunconsolidated material: Date drilled � '"�'". Description -man -Rwzk Water -bearing zones: CASING 1) From To Type ctePl 2) From To Length.—ft. Dia(I.D.)_6 in. 3) From To Length into bedrock 13 ft. Gravel pack well: dia. Protective well seal: Screen: dia. Grout -0 OtherDriveshae Slot"` length Irom_to STATIC WATER,LEVEL (all wells) Static water level below land surface—ft. Date�g WELL TEST (production wells) Drawdown b05 ft. after pumping hr..30 min. at. _ 7 gpm ,. How measured .frrig Recovery 1 OO ft, after�hr. min.:. _air 0 . LOG of FORMATIONS COMMENTS g Materials From. 'To a hpdrnr-k Driller H11gb tD Mr -Ki cgi ck Firm ,AWP CONTRACTORS Address 244A`HAVEN. .3T City/Town . Supe inn Drillear Reg :# A.5 ,mase pr,nc r"m'" 'BOARD OF. HEALTH COPS Permit No, -is- Towyn of i��i _ Arid�yer Massachusetts Board of Health reg' �v�d Date 10'/13/92 A-PPLICATION FOR WELL AND PLMP PERMIT Application is hereby mads for a permit is also made to install to drill or cepa r () a well, Application () major renovation () or major repair () of pump system, Locations Address great Pond Road Lot Nwber Owner I. Hefni Address Same 682-1900 Well Contra atorAvellino Well & Pump Address244A Haven Street, Readi ale hone #6177944-5454 Pump Contractor_Same Address Same WELL CONTele hone # TRACTOR (To be filled in 'at time of pulp test) Typo of Well' Artesian Well Used For Irrigation Diameter of Well 6" Site of Casing 64" Depth of Bed Rock , 8 Depth of Casing into Bed Rock 13 W u Seal Tested? Yes (x) No () Date of Testing 10%12/92 Depth of Well Sn�Well Ended in What Material Bedrock Depth to Water �n Delivers 10 Gallons/per/Minute Drawdown Id,Q feet after Pumping 4 lat ocation with tie' down lines on revers�eoofsthiGPM' _Sketch sap of well f Apra Date of Caapletion - 10/12/92 `- PLMP INSTALLER '(To be filled in before install 1 nl Con rac nature Size .and Name of Pump i Horse --,10 9Pm Jacuzzi Type of Pump Used .Submersible Water Pump. Delivers LQ.._..,_ GPM .'Site of Tank Well Rite 120 Pipe material wed in Well: Cast, Iron O Galvanized Plut is ( ) Well pit () or Pitless adapter Was sleeve used to protect pipe? Yes () No T>p Dat1041 12 Date water anal sis Y re port submitted to Board of Health Date release was given to ownsr.of record and Building Inspector p ctor Health Inapoctor ible NUMBER FEE 2 1� l e THE COMMONWEALTH OF MASSACHUSETTS TOWN, of --------- NORTH ANDOVER_._...... This is to Certify that ........ Avellino.._ well ... &___Pump...................................................... NAME 244A Haven Street, Reading, MA 01867 - .-•---••-•---.....-•-----------------------------•--•--------.._..........-•----...------•-•-•---.......--------------•••-•----...----....--••-----.._... ADDRESS IS HEREBY GRANTED A LICENSE For ......... Nell Permit - 940 Great Pond Road ..•••---•-•••••------------------•-••---------••---------------------...------•-•---------•-------••---•------------------•------------------ -••-------•---------------------------•-----•••••-----•• --•------•----------••------•••---••------...------•----•---------------------•---------------•------------------- This license is granted in conformity with the Statutes and ordinances relating thereto, and expires ---- Ilac-ember... 3.1.,...1992 ........... ._.�inless sooner n -------- De-eembe r---3.1,--------------19---9-2 ....... FORM 488 HOBBS & WARREN. INC. 7-11* --- - ............... --------------- Vto 0 h N W G a � a � `o C c > y a a � W N V r kn r - Vl M �D NUMBER FEE Z�L� THE COMMONWEALTH OF MASSACHUSETTS $25 �() a�L_.2�_ ..... Q1 M..... of ... R0.RTH-.-AXD.0.V R ----------------------. ------------- This is to Certify that ....... Ave llinoWell & Pump .. . .. ........... NAME ......24 .4A ... Haven ...S t r.e.e.t...,...- Re a dj.aq., ... NA01867 . -•--.........•-------•---•.................•-------•---•----- ADDRESS IS HEREBY GRANTED A LICENSE For .................... Wel.1---Permit... m --- 9.4.0 ... Graat--P4nd.... R4 a ----•---•----------••................•-•--•------••••-••-------•-•--••---•--•--•---•---•••----•....._...---•---------•----------•••.........---•-•--•---•--•-------•---- ......------•••------•---•--•• ••-•----••---•--------•---------------------•---------•--•-••--•---•••••-•--------------•---•-------••------••-•--••--------•------......-•--- ._....-------•...---•---••----•----•---.......-•--•••---•----•-----•••----•--••-------••-•........•-•------••-••-••---------•-•-••---••-•-••......-•---•--••---•--........ This license is granted in conformity with the Statutes and ordinances relating thereto, and expires --- December 31 . 1992 ess sooner s end 6i ed. October 7, '. --------------- - 19- 9 2 FORM ass HOBBS & WARREN. INC. 1. Nar 2. Str( WATERSHED RESIDENTS OUESTIONNAIRE 3. How many members are in your household? 4 What type of sewage disposal system do you have? ❑ cesspool &4' septic tank and leaching area ❑ connection to municipal sewer ❑ other (describe) ❑ do not know 5. Are the plans (drawings) for your sewage disposal system on file with the Board of Health? Lyes ❑ no ❑ do not know. 6. How old is your sewage disposal system? 52" "0-5 years ❑ 6-10 years ❑ 11-20 years ❑ over 20 years ❑ do not know 7. Has your sewage disposal system been rebuilt or repaired? ❑ yes P -no ❑ do not know If yes, approximately how long ago? years. What was done? 8. How frequently is your sewage disposal system pumped out? ❑ annually every 2-4 years ❑ every 5-10 years ❑ over 10 years ❑ never O9. Have you had any problems with your sewage disposal system? ❑ yes R no If yes, what problems? ❑ repeated pump -outs needed ❑ system clogs, backs up, or drains slowly ❑ odors ❑ sewage surfaces through ground 10. How many of each appliance are connected to your sewage disposal system? washing machine dishwasher garbage disposal dehumidifier drain NcAl E_ sump pump No^/ toilet roof/pavement drains /JoAf Vc shower/bathtub 11. Please state the bxand and type (liqu or powder) of detergent you use for: dishwasher `� <,—A�rf-'O�-� L' clotheswasher I /0 L,4 6 n !g- 12. Does your property have a lawn? L[J' yes ❑ no If yes, approximately what ssizz ? ❑ less than 1/4 acre Ltd 1/4 acre ❑ lh acre ❑ 3/4 acre ❑ 1 acre ❑ more than 1 acre (Specify) acres 13. How often do you fertilize your lawn? No. of applications per year r / OSeason(s) of the year 14. Please state the brand and type (liquid or granular)olawn fertilizer you use: Check here if your lawn is maintained by a professional landscape contractor. SEPTIC SYSTEM INSPECTION FORM ADDRESS 9 4 D G �ev�- QG ►�,� DATE INSPECTED PROPERLY FUNCTIONING? � N WEATHER CONDITIONS COMMENTS: