19 INTERVALE ROAD (002) �9 I.�rce d,�le 57�r
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No. 155L
HASTINGS. MN
LOS ANGELES-CHICAGO-LOGAN.ON
MCGREGOR.TX•LOCUST GROVE.GA
U.S.A.
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LIC : Town of .�/a/E✓�
Masschusetts
!✓1.6.L . C dl , See. �6 Board of Health
Permit No. Date 3-16-89
APPLICATION FOR WELL AND PUMP PERMIT
Application is hereby made for permit to drill or repair -a well. Application is
also made to install ( ) major renovation ( ) or major repair ( ) of pump system.
Location: Address 19 Tn PrvalP SYrPPY 4a1 eM TLQs Lot Number
Owner Peter DiTssn Address 16 Pratt Street , Salem, Mass .
Well Contractor dyr]es M Rnllind'n TTr Address 129 Depot Road, Boxfor
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Pump Contractor Address
WELL CONTRACTOR ( To be filled in at time of pump test ) MAR t 7 19F0
Type of Well Drilled Well Used For Domestic t , nu' SAIZM
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Diameter of Well 6�� ' Size of Casing 6HEALTH DEPT:
Depth of Bedrock 6 ' Depth of Casing into Bedrock 22 '
Was it Seal-Tested? YES ( ) NO ( ) Date of Testing
Depth of Well 305 ' Well Ended in What Material , Rock
Depth to Water 10 , Delivers 80 Gallons Per Minute
Drawdown feet after pumping hours at C.P.M. Sketch map of
well location with tie down lines on reverse side of this/form.
Date of Completion 3-14-89
/ L CONTRACTOR 'S SIGNATURE
PUMP INSTALLER ( To be filled in before installation )
Size and Name of Pump Type of Pump Used
Water Pump Delivers G.P.M. Size of Tank
Pipe Material Used in Well: Cast Iron ( ) Galvanized ( ) Plastic ( ) If plastic,
test strength
Well Pit ( ) or Pitless Adaptor ( )
Was sleeve used to protect pipe? YES ( ) NO ( ) Type or Name of Well Seal
Date
PUMP INSTALLERS SIGNATURE
x * r * +r r
Date water analysis report was submitted to Board of Health
Date release was given to owner of record and Building Inspector
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HEALTH .INSPECTOR