HomeMy WebLinkAboutHealth Permit # 9/23/2015 ......
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NUMBER
M COMMONWEALTH OF MASSACHUSETTS BHP-2015-0392
North Andover FEE 135.00
BOARD OF HEALTH
McKinney Artesian Well & Pump Supply Co., Inc.
NAME
138 LACY STREET
---------------------- _- -- --------------------------------
ADDRESS
IS HEREBY GRANTED A PERMIT
Well Construction
WELL
This permit is granted in conformity with the Statutes and ordinances relating thereto, and
expires ------------Decem -
ber 23- -,-2015_ unless sooner suspended or revoked.
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September 23, 2015 ---------------- ------------------ ---------- -------------- BOARD OF
------ - ---------- HEALTH
- ------------------ ----
_._------- ------.------------------------------
BOARD OF HEALTH CHAIRMAN
TOWN OF NORTH ANDOVER
Office of COMMIJNITY DEVELOPMENTAND SERVICES
HEALTH DEPARTMENT
1600 OSGOOD STREET; SUITE 2035
NORTH AI'NOVEL, 01845
Susan Y.Sawyer,REHS/RS 978.688.9540—Phone
Public Health Director 978.688.8476—FAX
healthdent atownoffiorthandover.corn
www.townofhorthan doves.con?
Well and/or Pump Application G
(Please print) DATE: / 2- 3
LOCATION to Drill Well or install a pump: e (3 h c'Ll s-C"
Licensed Well Contractor Name and Company Name: '37c'
Contact Phone Numt(ers:
60
r.........
Homeowner:
Pee�— A( 6oy,�-e
Address:— d4,v er- l01
f
Contact Phone Numbers: C o- 47.- 5 c, 7
WELLS(to be completed at time of pump test)
Type of well: Use:
Diameter of well: Size of Casing:
Depth of bedrock: Depth of casing into bedrock:
Seal been tested? Yes( No( Date of test:
Depth of well: Water-bearing rock:
Depth of 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: Type:
Size of Tank: Pump delivers: GPM
Pipe used in well: Cast Iron— Galvanized Plastic
Sleeve used to protect pipe? Yes No Type of well seal:
Date:
Signature of Pump Installer
Date water analysis report submitted to Health Department:
Plumbing Wiring Inspector Health Department Representative
C:\Users\bcurran\AppData\Local\Microsoft\Windows\Temporary Internet Files\Content.Outlook\S37IW8E9\Well-
Pump Application May 2015.doc
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