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1490 GREAT POND ROAD Odd
J 210/062.0-0029-0000.0
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B O ARD OF HEALTH
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• 120 iv1AIN STREET TEL. 682-6483
~"�SACNUSE��� NORTH ANDOVER, MASS. 01845 ExcZ3
APPLICATION FOR ABANDONMENT J
OF SUBSURFACE DISPOSAL SYSTEM ,L
(SEPTIC SYSTEM) �✓'k
PURSUANT TO SEC`T'ION 310 CMR 15 . 30-4
OF THE STATE ENVIRONMENTAL CODE, TITLE V
This form must be submitted to the Board of Health no less than
vivo ( 5) days prior to date of abandonment and be accompanied with
a copy of the sewer connection permit.-
Name ���a Phone
Address / y 9'0
Contractor hired for work:
Name Phone
Address J7 Ll
7
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
,t
N0- 1147
APPLICATION FOR SEWER SERVICE CONNECTION
North Andover, Mass. 19
Application by the undersigned is hereby made to connect with the town sewer main in 4zi l Street,
subject to the rules and regulations of the Division of Public Works.
The premises are known as No. /-� �d ���1 Street
or suhdaisionlot no.
46
O �r'2 �� Address
Contractor Address
Applicant's Signator
; 2Z)
PERMIT TO CONNECT WITH SEWER MAIN
The Division of Public Works hereby grants permission to
to make a connection with the sewer main at Street
subject to the rules and regulations of the Division of Public Works..
Division of Public Works
By
Inspected by
Date
See back for rules and regulations
BOARD OF HEALTH
t46 ;MAIN STREET
TELEPHONE# (508) 688-9�
APPLICATION FOR ABA= /VD0.{-`1E.':"T
0
OF SG'BS('"RFACE DISPOS,iL S-S7T.�I
(SEPTIC SYSTEM)
Pursuant to Section 310 CMR 13.35-1
of the State Envirojunental Code, Title V
Name � (v 8Pho _
Address /d 9 o
Contractor hired for work:
Name OLHYo C Phone
Address 54 13
Date for scheduled abandonment
The septic system at the above addre4beenoped according to
Title V specifications.
f Contractor
Method of septic tank abandonment (check one). O removal O sandfill
(P crush ( ) other
Name of Offal Hauler �Amopi
This form must be returned to the North Andover Board of Health.
PLEASE DO NOT WRITE IN THE SPACE BELOW FOR HEALTH
REPRESENTATIVE'S USE ONLY.
17
Inspecting Agent Date