HomeMy WebLinkAboutMiscellaneous - 150 BRENTWOOD CIRCLE 4/30/2018 150 BRENTWOOD CIRCLE C"
210/064.0-0056-0000.0
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3+ '4t,``o '•1tioL BOARD OF HEALTH
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120 MAIN STREET TEL. 682.6483
9SSICHUSEt NORTH ANDOVER, MASS. 01845 Ext23
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SOARD
APPLICATION FOR ABANDONMENT SEP W
OF SUBSURFACE DISPOSAL SYSTEM
(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 thesewerconnection permit.
NamePhone
Address �� (Z1Z&i 2( �t-C.�-fit/ Cl✓Z
Contractor
hired for work: �(
• Name --� � \ C _ Phone
Address
Date for scheduled abandonment O
Method of septic tank abandonment (check one) .
( ) removal ( ) sandfill rush ( ) other (describe
below)
Other
PLEASE DO NOT WRITE IN THE SPACE BELOW
. FOR HEALTH AGENT'S USE ONLY
I��[T5
Inspectg1Ag1r1enf Date
Comments ✓t
•
N° 965 APPLICATION FOR SEWER SERVICE CONNECTION
North Andover, Mass. 5,61 19 1 E
Application by the undersigned is hereby made to connect with the town sewer main in �1�� cy Cly Street,
subject to the rules and regulations of the Division of Public Works.
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The premises are known as No. �� K iJ a �L Street
or subdivision lot no.
Owner Address
Contractor Address
Applicant's Signature
• �Qq�L� � c�Q c
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