HomeMy WebLinkAboutMiscellaneous - 523 OSGOOD STREET 4/30/2018 (2) 523 OSGOOD STREET it
210/036.0-0006-0000.0
1
BOARD 01' [JEAL-1-1-1 - �y.
146 N I A FN STREET
TELEPHONE9 (508) 688-9540
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.4"TL10 -TION F'O!LA I,'A.;V1', "EVT
OF SUBS1JU-,,4 CE DISPOSAI L S-KSTE,,M
(.SF-P 7 1 C S YS TE,V)
Pursuant to Sectloi! 310 0,1,,,-> 354
of the State EnVil-017Mental Codd. Tale V
CUM, SLC'j,—
Address -5 A-?�
Contractor (tired for work:
Name '131ione Q� — 744,5-
Address 44
Date for scheduled abandonment
The septic system at the above address has been abandoned accordincr to
Title V specifications.
Signature of Contractor
Mjthod of septic tank abandonment (check one). O removal sandfill
rv�
^crush ) 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 Date'
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