HomeMy WebLinkAboutMiscellaneous - 40 FERNCROFT CIRCLE 4/30/2018 40 FERNCROFT CIRCLE
210/103.0-0101-0000.0 cle
NOR7)y
�? °p BOARD OF HEALTH
, _,,,*, • _ 120 MAIN STREET TEL. 682-6483
'SSACH„SE{`y NORTH ANDOVER, MASS. 01845 EX123
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.
NamePhone
Address -</6 r-oeticeaPT'CAcke-
Contractor hired for work:
Name ^�� �� 24z Phone 4�
Address 13�) J9 F&1,2/�1 ov SZ"
Date for scheduled abandonment
Method of septic tank abandonment (check one) .
( ) removal ( ) sandfill (rush ( ) other (describe
below)
Other
PLEASE DO NOT WRITE IN THE SPACE BELOW
FOR HEALTH AGENT ' S USE ONLY
Inspecting Agent Date
Comments
w
.aO R'h
BOARD OF HEALTH
` 120 S 1 REE 1 TEL. 682-64,83
A3
'J'74CHU5Et NORTH ANDOVER, MASS. 01843 Exc23
APPLICATION FOR ABANDONMENT �`m
OF SUBSURFACE DISPOSAL SYSTEM
(SEPTIC SYSTEM)
PURSUANT TO SECTION 310 Ci,[R 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 , c Phone
Address Cf U
Contractor hired for Work:
Name ?. CZ,a.-- Phone
Address
Date for scheduled abandonment
Method of septic tank abandonment (check one) .
( ) removal ( ) sandfill ( ) crush ( ) other (describe
Other
PLEASE DO NOT WRITE IN THE SPACE BELOW
FOR HEALTH AGENT ' S USE ONLY
Inspecting Agent Date
Comments
k
N° 1142
APPLICATION FOR SEWER SERVICE CONNECTION
North Andover, Mass. l Z 19
Application by the undersigned is hereby made to connect with the town sewer main in r J�l�' ' 7Y Street,
subject to the rules and regulations of the Division of Public Works.
The premises are known as No. G��I G'llJ Ci�! Street
or subdivision lot no.
Owner Address
/11 4110 �7
Contractor Address
licant's Signature
g T)
d
CoAlR V4-770,'V o7—
TZLO
PERMIT TO CONNECT WITH SEWER MAIN
The Division of Public Works hereby grants permission to
to make a connection with the sewer main at Street
subject to the rules and regulations of the Division of Public Works..
Division of Public Works
By
Inspected by
Date
See back for rules and regulations