HomeMy WebLinkAboutMiscellaneous - 123 BRENTWOOD CIRCLE 4/30/2018 rI Dv.5 ctJ-'Cr
12
123 BRENTWOOD CIRCLE v
2l0/aosa.o-Doss-0000.o -- - - - - - - - -- - _ _-- -- -
c J
I OKA Sew e.,vm-
�I
AORTil
.I �Oy tato ,tiO
3 - - BOARD OF HEALTH
`•�9 �Y 120 MAIN STREET 682-6483
SAC`HUSNORTH ANDOVER, MASS. 01 WN pF No oEN �SN xt23
Zp gpPR
Sti
APPLICATION FOR ABANDONMEN
OF SUBSURFACE DISPOSAL SYSTE
(SEPTIC SYSTEM)
PURSUANT TO SECTION 310 CMR 15.354
OF THE STATE ENVIRONMENTAL CODE, TITLE V
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
a copy of the sewer connection permit.
Name ���-�V Phone
Address J �� i2P,y u'-oo k2I
Contractor hired for work:
Name
c7 GLA- 12c.IC Phone
I
Address A/ <�i4`
I
Date for scheduled abandonment C?/
i
Method of septic tank abandonment (check one) .
I
( ) removal (ti(sandfill (crush ( ) other (describe
below)
Other.
PLEASE DO NOT WRITE IN THE SPACE BELOW
FOR HEALTH AGENT'S USE ONLY
I
Inspecting A nt Date
Comments
j
a
i
I
{
r� • '4.
.ate A
! %=MOO
VN
i
i.
AS S;-•.;j`4 AND #AT 7Hr- :, kJC lCN 3^L? Ek3ALS ,
C- ?t-•p ...4' . •,� , .{ � �
ARE
RE`"a} tfr'`j•c _L 'H �.L.'•.�.�;if'..rP':.T3^#t'.:r�"i,�S(!}Iii
t. L tt`; ' '..A-l01, A# [-' ! } .Pc.XT t''t 1' r,tP'#CIN
PLAtL�uY AQ(PIER ufJW�JJAN`I
traw,0ATE Ll r,-23—t;
s
f
,...�._41. �,'���i. rlC"t� ,4^!—ate.,�'•� �.�� .' 4
C,4T1OK- J(
is-E,x;)►fTf-r-T 20 QA' E 7 2 �C.ALE 1=40 `
Ef-.D FEUD
. # ��� /? !/fJ' .' r � / J�-�lt•..� �,! j'�1,�. � 5��� �� �L/� 'f'�fa}f/�"�l�/
#
1,
II