HomeMy WebLinkAboutMiscellaneous - 42 HIGH WOOD WAY 4/30/2018 42 HIGH WOOD WAY
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SEWE"OR
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�j BOARD OF HEALTH
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120 MAIN STREET TEL. 682-6483
S-TACH jS'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. /G
or
Name Phone bo -Ojo/.
Address
Contractorhiredfor work:
OName /_.s✓r�� ah1�.,�.�.o� . Phone
Address c� 1�� �Yy r�` /UQ �9r✓o e 01r Yf
Date for scheduled abandonment 26
Method of septic tank abandonment (check one) .
( ) removal ( ) sandfill ( crush other (describe
below)
Other
LEASE DO NOT WRITE IN THE SPACE BELOW
FOR HEALTH AGENT' S USE ONLY
In ec ing Agent Date
Comments
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