HomeMy WebLinkAboutMiscellaneous - 1046 GREAT POND ROAD 4/30/2018cri
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BOARD OF HEALTH
120 MAIN STREET
NORTH ANDOVER, MASS. 01845
APPLICATION FOR ABANDONMENT
OF SUBSURFACE DISPOSAL SYSTEM
(SEPTIC SYSTEM)
PURSUANT TO SECTION 310 CMR 15.354
OF THE STATE ENVIRONMENTAL CODE, TITLE V
TEL. 682-6483
Ext23
This form must be submitted to the Board of Health no less than
five (5) days brior to date of abandonment and be accompanied with
a copy of the sewer connection permit.
Name Phone
Address Lj C - a—
OContractor hired for work:
Name
Address
Date for scheduled abandonment
Phone
Method of septic tank abandonment (check one).
( ) removal ( ) sandf ill ( ) crush ( ) other (describe
below)
Other 7
PLEASE DO NOT WRITE IN THE SPACE BELOW
FOR HEALTH AGENT'S USE ONLY
Inspecting Agent
Comments
Date
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BOARD OF . HEALTH
120 MAIN STREET
NORTH ANDOVER, MASS. 01845
APPLICATION FOR ABANDONMENT
OF SUBSURFACE DISPOSAL SYSTEM
(SEPTIC SYSTEM)
PURSUANT TO SECTION 310 CMR 15.354
OF THE STATE ENVIRONMENTAL CODE, TITLE V
TEL. 682-6483
Ext23
This form must be submitted to the Board of Health no less_'than
five (5) days prior to date of abandonment and be accompanied with
as copy of the sewer connection permitof the sewer connection permit.
Name Phone
Address
OContractor hired for work:
Name Phone
Address
Date for scheduled abandonment
Method of septic tank abandonment (check one).
( ) removal ( ) sandfill ( ) crush ( ) other (describe
below)
Other
PLEASE DO NOT WRITE IN THE SPACE BELOW
FOR HEALTH AGENT'S USE ONLY
Inspecting Agent Date
Comments
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