HomeMy WebLinkAboutMiscellaneous - 550 BOXFORD STREET 12/28/2015 (6) i
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COMMONWEALTH OF MASSACHUSETTS NUMBER
BHP-2015-0082 I
North Andover FEE
BOARD OF HEALTH $135.00
Charles M. Rollins, Inc.
-------- -------------------------------------------------------.
NAME
BOXFORD STREET
-------------- --------------- ------------------------------------
ADDRESS
IS HEREBY GRANTED A PERMIT
Well Construction
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Well-Lot 2
This permit is granted in conformity with the Statutes and ordinances relating thereto, and
expires June 30, 2015 unless sooner suspended or revoked.
p ------------- - -
---- ------ -- ------- ------- ---------------- BOARD OF
March 31, 2015 I --- HEALTH
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BOARD OF HEALTH CHAIRMAN
TOWN OF NORTH ANDOVER ,.
Office of COMMUNITY DEVELOPMENT AND SERVICES
HEALTH DEPARTMENT
1600 OSGOOD STREET, SMITE 2035
NORTH ANDOVER, MASSACHUSETTS 01845
Susan Y. Sawyer,REHS/RS 978.6889540-Phone
Public Health Director 978.688.8476-FAX
healthdept@towiiofiiorthandovei-.com
wtivw.townofitorthandovei-.com
Well and/or Pump Application _ / a
(Please print) DATE:
L®CATION to Drill Well or install a pump:
Licensed Well Contractor Name and Company Name: C WUC S JIVI, 1�?V LLI'NS Cc. _r-:tj cd
i
Contact Phone Numbers:- a s 29.1_ Z 3 C '? 3-75-- �JP
Homeowner ►" S�S i' �'-
Address: oZ 1 ..7 Of 4S W t'Ije-Yb wll Oev V'21,+i '0, to
Contact Phone Numbers:—q 3 -7 5
WELLS(to be completed at time of pump test)
Type of well:— ® C1� Use: �-
ii / L/
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: GP
Date of Completion: `
Signature o ell Contractor
PUMPS(To be filled in before installation)
Name&z 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 sea]:
Date:
Signature of Pump Installer
Date water analysis report submitted to Health Department:
Plumbing Wiring Inspector Health Department Representative
S:\Health\Permit Applications\Well Application.doc
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Town of North Andover
�4 y HEALTH DEPARTMENT
�CK#:: DATENIMPA
LOCATION:
H/O NAME: t/y
CONTRACTOR NAME:
Type of Permit or License: (Check box)
• Animal $
• Body Art Establishment $
❑ Body Art Practitioner $
❑ Dumpster $
❑ Food Service-Type: $
❑ Funeral Directors $
❑ Massage Establishment $
❑ Massage Practice $
❑ Offal(Septic)Hauler $
❑ Recreational Camp $
❑ Sun tanning $
❑ Swimming Pool $
• Tobacco $
• Trash/Solid Waste Hauler $
• Well Construction $
SEPTIC Systems
tems:
❑ Septic-Soil Testing $
❑ Septic-Design Approval $
❑ Septic Disposal Works Construction(DWC) $
❑ Septic Disposal Works Installers(DWI) $
❑ Title 5Inspector $
❑ Title 5 Report $
❑ Other:(Indicate) $ Wo
Health Agent Initials
White-Applicant Yellow-Health Pink-Treasurer
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MESSA. DEVELOPMENT COMPANY9 10
277 Washington Street
Grove➢and, AIA 01834
978®891®3190
March 31, 2015
Dear Michelle,
I understand that the septic designs have not yet been approved by the
BOH and I accept full responsibility for the location and installation of the
wells on lot 1 & 2, Boxford St.
Sincerely,
Bob Messina
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TOWN OF NORTH ANDOVER �o t
Office of COMMUNITY DEVELOPMENT AND SERVICES
HEALTH DEPARTMENT
1600 OSGOOD STREET; SUITE 2035
NORTH ANDOVER,MASSACHUSETTS 01845
978.688.9540—Phone t
Susan Y.Sawyer,REHS/RS 978.688.8476—FAX
Public Health Director E-MAIL: ltealthdeptL(vtownofnorthandover.com
WEBSITE:http://www.townofnorthandover.com
SEPTIC PLAN SUBMITTAL FORM
Date of Submission: J /
„y, yy
Site Location: 6a l25X. td�
Engineer: (,�V'1
New Plans? Yes $225/Plan Check# G& (includes I"submission and one re-
review only)
Revised Plans?Yes $75/Plan Check# -
Site Evaluation Forms Included? Yes k' No
Local Upgrade Form Included? Yes No
Telephone#: q79-313-6316 Fax#:
E-mail: c_)h 1 L C 5G — erl�f . cb m
Ilemeawnere v Ul o�e2
Name: A ee.5 i zi to D'f V ej a to Im 6 yz c oaq „
OFFICE USE ONLY
When the submission is complete (including check):
➢ Date stamp plans and letter
Complete and attach Receipt �
Copy File; Forward to Consultant
➢ Enter on Log Sheet and Database bbl L 2015
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