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BOARD OF HEALTH
If 120 MAIN STREET
NORTH ANDOVER, MASS. 01845
APPLICATION FOR ABANDONMENT
OF SUBSURFACE DISPOSAL SYSTEM
(SEPTIC SYSTEM)
TEL. 682-6483
Ext 23
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. G
Name - 0L Phone
Address �
Contractor hired for work:
• Name ® Phone (T� � 3 - S
Address
Date for scheduled abandonment
Method of septic tank abandonment (check one).
( ) removal ( ) sandfill Ar rush ( ) other (describe
below)
Other
PLEASE DO NOT WRITE IN THE SPACE BELOW
FOR HEALTH AGENT'S USE ONLY
Inspecrt,:�nhg n
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