HomeMy WebLinkAboutMiscellaneous - 571 FOREST STREET 8/25/2015 1
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THE COMMONWEALTH OF MASSACHUSETTS
TOWN OF NORTH ANDOVER
BOARD OF HEALTH
Permit # 021
Fee: $50.00
Date: 6/29/01
This is to certify that: C.M. Rollins Co., Inc.
IS HEREBY GRANTED A LICENSE
FOR THE PURPOSE OF DRILLING A WELL AT:
571 Forest Street
This license is granted in conformity with the statutes and ordinances
relating thereto, and expires DECEMBER 31, 2001 unless sooner
suspended or revoked.
Gayton Osgood, Chairman
Francis P. MacMillan, M.D., Member
John S. Rizza, D.M.D., Member
o tao iy A/0
w° w,lo� " BOARD OF HEALTH
`" �t NORTH ANDOVER, MASS. i s,<�
APPLICATION FOR WELL AND PUMP PERMIT
Permit # Date (r?
A permit is requeste'd��'' to: drill a well install a pump
LOCATION: t-Z o Lot #
Owner 4A'A1_r\ G-4 r! Address VA I-f VQIP-Z NA , Tel q7;F 77 7-S13 7 2.
Well Contrctr Co. yVl. ����wS � JC. Add. .`vI� n�'� G� d. I\A , Tel 79° (yyy P 2 3 z-0
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Pump Contrctr Uy�w� Add. Tel
WELLS (To be completed at time of pump test. )
Type of well Use
Diameter of well Size of casing
Depth of bed rock Depth casing into bedrock
Seal been tested? Yes (_) No (_) Date of test
Depth of well Water-bearing rock
Depth to water Delivers GPM for
(how long?)
Drawdown feet after pumping hours at GPM
Date of completion _
Signature of well contractor
PUMPS (To be filled in before installation. ) .
Name & size of pump C p
Size of tank Pump delivers �r� vGP'
Pipe used in well : Cast iron (_) Galvanized' (_) Plastic (_)
Sleeve used to protect pipe? Yves (_) No (_) Type well seal
Date
Signature of pump installer
Date water analysis report submitted to Board of Health
Plumbing inspector Wiring inspector-
2
Board of Health
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DES/GAJ DATA
ryope of 4q&/za/r/a z1 d,�. � I/INc-
dARArcr � CEDAR 044/AtSM/4 xrAc11-1r 1(5s /V,,,9 ,
,,6WAGE FLOW EAST/MA rE :
SEPT IC TRAtK : 1,570 o G�19 Z-
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CERT'/F/ED FOUNDA RON PL AN
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SCALE./ A-12' DA7-E, L> l*.I
5L.GILES R.L.S.
L AWRENCE 8 NORTH ANDOVER
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✓ cERTIFY 71-IAT TIVE OFFSET'S SHOWN ARE FOR THE USE OF
01-FSF TS SHOWN ITHE BU/L DING INSPECTOR ONLY, 8 SUCH
G'C1/�✓FC�,YM
7-0 THE USE /S FOR DETERMINATION OFZON/NG
%r'-','N✓,v6" ,1Y Y ✓..A W OF CONFORMITY OR NON CONFORMITY
kVHZ--N CONS TRUC TED
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TOV�VN 4F' NORTH ANDOVER
SYSTEM PUMPING RECORD
DATE:
SYSTEM OWNER& ADDRESS SYSTEM LOCATION
exam front of
(example: left P f house)
f 9 y c � r
DATA OF PUMPING: I QUANTITY PUMPED �. GALLONS
t
r, CESSPOOL: NO YES SEPTIC TANK: NO YES
NATURE OF SERVICE: ROUTINE EMERGENCY_
a
r�� 7 � ' � � IONS• �°�
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GOOD CONDITION' FULL TO COVER
' HEAVY GREASE BAFFLES IN PLACE
ROOTS LEACHFIELD RUNBACK
EXCESSIVE SOLIDS FLOODED
SOLIDS CARRYOVER OTHER (EXPLAIN)
SYSTEM PUMPED BY:
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