HomeMy WebLinkAboutMiscellaneous - 212 BRENTWOOD CIRCLE 4/30/2018 212 BRENTWOOD CIRCLE ;cle
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BOARD OF HEALTH
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M OF NORTH
• r° 120 MAIN STREET BOARD OF HEALT L. 2.6483
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SS^CHUSE NORTH ANDOVER, MASS. 0184 E 23
,W 21 1995
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—ofd the sewer connection permit. ,t
Name r o... 12yl,�rL_ Phone (P
Address (,� I -j 13"oA�-odO
Contractor hired for work:
• Name �-►" 30C4 Q r�Phone � "� 0
Address UatL ,
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
Insp cti gent 7 Date
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