HomeMy WebLinkAboutMiscellaneous - 222 BRENTWOOD CIRCLE 4/30/2018 -11
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2101064.40053-DODD.D
ON
NEWER
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BOARD OF HEALTH
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120 MAIN STREET TEL. 682-6483
,SSAcwUS�t NORTH ANDOVER, MASS. 01845 Ext23
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. p-
Name 61' L-1 Phone (/79-
/79- "-10 1 Q
Address ZZZ �3feo LA)agz l 0L
Contractor hired for work:
Name Phon S67 XS-/ ' 2 r. �s Z
Address d / �✓�5
Date for scheduled abandonment AS7-
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 7-�2 P lq
-5-
p in gent Date
Comments ?
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