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BOARD OF HEALTH
120 MAIN STREET
NORTH ANDOVER, MASS. 01845
APPLICATION FOR ABANDONMENT
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—%R,5, ("per' , � �� Phone
Address I� C
Contrac�t�o-r- hired for work:
Name
Address
;0 L 1Nlc
Date for scheduled abandonment
Phone
W34,
Method of septic tank abandonment (check one).
( ) removal ( ) sandfill ( crush
Other
( ) other (describe
below)
PLEASE DO NOT WRITE IN THE SPACE BELOW
FOR HEALTH AGENT'S USE ONLY
Inspecting Agent
Comments
Date
TOWN OF NORTH ANDOVER/
N° 913 BOARD OF HEALTH
JUN - 6 In
APPLICATION FOR SEWER SERVICE CONN ECTI N
North Andover; Mass. 19
Application by the undersigned is hereby made to connect with the town sewer main in +a' ��`2 ar�n'— Street;
subject to the,rules and'regulations of the Division of Public Works.
The premises are known as No. 7L'�� i�C✓L ( Street
or subdivision lot no.
Owner Address
Contractor Address
�M .. VV
pPlic is S. ature .
. ... .. it ,. .. ,.. .. .. .. ,
PERMIT TO CONNECT WITH SEWER MAIN
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The Division of Public Works hereby grants permission to
to make a connection with the sewer main at
subject to the rules and regulations of the Division of Public Works.
Inspected by
Date
Street
Diyisio , f P blic Works
By
See back for rules and regulations
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