HomeMy WebLinkAboutMiscellaneous - 1492 GREAT POND ROAD 4/30/2018 (2) _ 1492 GREAT POND ROAD Road
2101062.0-0030-0000.
BOARD OF HEALTH
146 MAIN STREET
TELEPHONE# (508) 688-9540
APPLICA TION FOR ABANDOA`:i E—A-T
OF SUBSURFACE DISPOSAL SYSTEM
(SEPTIC SYS TEV)
Pursuant to Section 310 CMR 15.354
of the State Environmental Code, Title V
Name �j11( /j /� Phone
Address
Contractor hired for work:
Name Y,rd 7,'- Phone l- Z23
Address e/
Date for scheduled abandonment -L?
(h6
The septic system at the above address has been abandoned according to
Title V specifications. QQ �
Signature of Contractor
Method of septic tank abandonment (check one). O removal O sandfill
(`) crush ( ) other
Name of Offal Hauler ?2
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.
t r Z7 q
Inspecting Agent Date