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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
TEL. 682-6483
Exr23
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 co-ov of the sewer connection permit.
Name Phone
Address
Contractor hired for work:
Name Phone
/>
.Address
Date for scheduled abandonmen
Method of septic tank abandonment
( ) removal
Other
( ) sandf ill
(check one).
crush other (describe
below)
PLEASE DO NOT WRITE IN THE SPACE BELOW
FOR HEA1jTH AGENT'S USE ONLY
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Comments
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1062
APPLICATION FOR SEWER SERVICE CONNECTION
North Andover, Mass. 73 19 fi�--
Application by the undersigned is hereby made to connect with the town sewer main in Street,
subject to the rules and regulations of the Division of Public Works.
The premises are known as No. 204 Street
or subdivision lot no.
Owner
- Ale I 1�1(C-11- (�7w -i
Contractor
Address
PERMIT TO CONNECT W
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..
By
Inspected by
Date
SEWER MAIN
See back for rules and regulations
I
Street
Division of Public Works