HomeMy WebLinkAboutMiscellaneous - 191 BRENTWOOD CIRCLE 4/30/2018 191 BRENTWOOD CIRCLE
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210/064.0-0043-0000.0
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,IORTA,
BOARD OF HEALTH
"�99D. {D✓�`ty 120 MAIN STREET TEL. 682-6483
9SSICHUSES NORTH ANDOVER, MASS. 01845 aNpp a t23
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APPLICATION FOR ABANDONMENT SEp 19
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 the sewer connection permit
Name_ �U 12GpM C> Phone 61.(
Address 1 \ J1k2 ( ,
Contractor hired for work:
• Name Sow Phone
Address w1 eli� 4E±L' u vVV4 .
Date for scheduled abandonment / o�
Method of septic tank abandonment (Le one) .
( ) removal ( ) sandfill ( crush ( ) other (describe
below)
Other
PLEASE DO NOT WRITE IN THE SPACE BELOW
FOR HEALTH AGENT'S USE ONLY
Ixd'po,eting Agent l
Da e
Comments
•
,s . 4
N° 967
ID
APPLICATION FOR SEWER SERVICE CONNECTION
North Andover, Mass. j 19 LL
Application by the undersigned is hereby made to connect with the town sewer main in l7//�1G9 t�ll Street,
subject to the rules and regulations of the Division of Public Works. 1 /�
The premises are known as No. l 9� ���e�1 r6�/� C l� Street
or subdivision lot no.
Owner Address
Contractor Address
Applicant's Signature
9 '
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
•