HomeMy WebLinkAboutMiscellaneous - 420 MARBLERIDGE ROAD 4/30/2018 (2) 420 MARBLERIDGE ROAD :Odd
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146 MAIN STREET
ELEPHONE# (508) 688-940 OF d R
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.4PPLICA TIOAT FOR .!BANDO,\_'VfENT NflV 191996
OF SUBSURFACE DISPOSAL S�:S7-,,M
(SEPTICSYS7EVj
Pursuant to Section 310 CMR 15.354
of the State Environmental Code, Tale V
97
Name l'Gcwt_ �' P1 one 1l-,."
Address 4Z� f .2-9 4
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Contractor hired for work:
Name Phone
Address Zb '
Date for scheduled abandonment_ It
The septic system at the above address has been abandoned according to
Title V specifications.
Signature of Contractor
Method of septic tank abandonment (check one). O removal O landfill
( crush O other
Name of Offal Hauler �,`�
This form must be returned to the North Andover Board of Health.
PLEASE DO NOT WRITE IN THE SPACE BELOW FOR HEALTH
REPRESENTATIVE'S
USE ONLY.
Inspecting Agent /496
Date
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