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NORTH
3? ` BOARD OF HEALTH
ACHUSEt�h NORTH 2AND VER, MAESS. 0184 E t2 383
,um 19 1995
APPLICATION FOR ABANDONMENT
OF SUBSURFACE DISPOSAL SYSTE
F __j
(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 e-rmit-.-:,, /
Name ' Phone � 4g 9Z�/ V-
Addresses
Contractor hired for work: 17-
Name <e x) �` ` Phone -3 �7 / �' T
Address
Date for scheduled abandonment
Method of septic tank abandonment (check one) .
( ) removal (`�(f sandfill ( ) crush ( ) other (describe
below)
Other
PLEASE DO NOT WRITE IN THE SPACE BELOW
FOR HEALTH AGENT'S USE ONLY ��77
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DAp `q
,rZngent Daae
Comments 6'
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