HomeMy WebLinkAboutMiscellaneous - 562 SALEM STREET 4/30/2018 562 SALEM STREET
210/038.0-0102-0000.0 f
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BOARD OF HEALTH
400 OSGOOD STREET
NORTH ANDOVER,MA 01845
TELEPHONE# (978) 688-9540
APPLICATION FOR ABANDONMENT
OF SUBSURFACE DISPOSAL SYSTEM
(SEPTIC SYSTEM
Pursuant to Section 310 CMR 15.354
of the State Environmental Code, Title V
Name . '
Phone_
q�
Address
Contractor hired for work:
Name Phone
Address uwj
Date for scheduled abandonment
The septic system at the above address has be abandoned according to Title V
specifications.
Signa n factor
Method of septic tank abandonment(check one). O removal O sandfill crush
( ) other
Name of Offal Hauler �� .Ci 7 C ' � Ml ►J
This form must be returned to the North Andover Board of Health.
PLEASE DO NOT WRITE IN THE SPACE BELOW FOR HEALTH
PRESENTATIVE'S USE ONLY. "
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