HomeMy WebLinkAboutMiscellaneous - 95 LACY STREET 4/30/2018 (4)°L
MASSACHUSETTS PROPERTY INSURANCE UNDERWRITING ASSOCIATION
Two Center Plaza
Boston, Massachusetts 02108-1904
(617) 723-3800, Ma Only (800) 392-6108, Fax (617) 557-5675
Form of Notice of Casualty Loss to Building
Under Mass. Gen. Laws, Ch. 139, Sec.313
NORTH ANDOVER HEALTH DEPT.
NORTH ANDOVER TOWN HALL
NORTH ANDOVER MA 01845
Re: Insured:
Property Address:
Policy Number:
Type Loss:
Date of Loss:
Claim Number:
BARBARA B. TIGHE
LACY STREET, NORTH ANDOVER, MA 01845
0628862
Lightning (not resulting in Fire)
09/07/01
188573
09/14/01
IV. /&�, D -6170
Li) 1/J t l p g(OrLe-)d
Fa f -/,,U
Claim has been made involving loss, damage or destruction of the above captioned property,
which may either exceed $1,000.00 or cause Massachusetts General Laws, Chapter 143,
Section 6 to be applicable. If any notice under Massachusetts General Laws, chapter 139
Section 3 B is appropriate, please direct it to the attention of the writer and include a
reference to the captioned insured, location, policy number, date of loss and claim or file
number.
MPIUA Claims Division
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Commonwealth of Massachusetts
&jj M-C-v'r' , Massachusetts
System Pumping Record
System Owner System Location
K I"
(7
Date of Pumping:
Cesspool: No Yes
6-0
1
Quantity Pumped:
Septic Tank: No L. J
System Pumped by: FarwOrt Efla ,61ided
gallons
Yes
License #
Contents transferrred to : Greater Lawrence Sanitary District
Date: Inspector.
Sep 23 09 02:26p William M. Hurley,Esq. 978 452 5726
p.4 `
BOARD OF HEALTH
Town of North Andover,Mass.
Permit #
Date 19- --
89 APPLICATION FOR WELL & PUMP PERMIT
&pplication is hereby made for permit to drill a well (x.). Application i's
made to install (—) a pump system.
Location: Address Lacy Street, North Andover, MA ..Lot # _
Owner Ralph Shea Address 3 Pine Ave.,Wilmington,MA Tel.
dell Contra c t o r Charles M. Rollins Qo. , )nc. Address 129 Dspot Rd. , &fiord M& T e 1508-887-2,320
Pump Contractor Address Tel..
WELL CONTRACTOR
(To be completed
at time
of pump test)
Type of Well
Drilled
Well
used for Domestic
Diameter of Well
6"
Size
of Casing 6"
Depth of Bed Rock
33'
p•
De t.h
casin 54'
E into Bed Rock
Was Seal Tested?
Yes ( ) No (_)
—
Date.
�
of Testing
Rock
D e pt -h .. o -f 1Uel-1
530'
—
Well
Ended in What. Material
Depth to Water
516" Delivers 3 Gals.Per Min. for 4 hours
Drawdown feet after pumping __}-lours at GPM
Date of Completion -3-89
Signature Wel Contractor:
PUMP INSTALLER (To be- f-ill'cd in- before i.nstall.ation)
Size & Name Pump _ __ _ �.__Pump Type Used
slater Pump Delivers GPM Size of _Tank
Pipe Material Used in Well: Cast Iron (_) Gnl.vnni.zed (_)
14ell Pit ( ) or Pitless Adapter (^)
Plastic (—I
Was sleeve used to protect pipe? Yes (_) NO(_) 'Type or Name Well Seal
Date p
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Date Water analysis repor-t submitted to Board of 1ie6l'th
Date release given tD owner of record & Bldg. Insp
Health Inspector
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