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BOARD OF HEALTH
120 MAIN STREET
NORTH ANDOVER, MASS. 01845
APPLICATION FOR ABANDONMENT
OF SUBSURFACE DISPOSAL SYSTEM +
(SEPTIC SYSTEM)
TEL. 682-6483
Ext 23
s
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 4 Phone
Address
Contractor hired for work: ,,99
Name �vl,�_ � Phone � o'
Address > -v , A/� Aloael—
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
Date
Inspecting Agent
: I
Comments
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