HomeMy WebLinkAboutMiscellaneous - 573 SALEM STREET 4/30/2018 (6) _ 573 Salem Street
Tank Crush - 9/26/05 - - - - -
BOARD OF HEALTH
400 OSGOOD STREET
NORTH ANDOVER,MA 01845 RECEIVED
TELEPHONE# (978) 688-9540
APPLICATION FOR ABANDONMENT SEP 2 3 2005
OF SUBSURFACE DISPOSAL SYSTEM TOW,N OF NORTH ANDOVER
I
(SEPTIC SYSTEM) HEALTH DEPARTMENT
Pursuant to Section 310 CMR 15.354
of the State Environmental Code, Title V
Name 'E:A�D poJ t.A yZ-L< y-,..i Phone —1 \ —0144-1 S D$
Address C ttj Ofic<r-4�-- S -TE:;,, 1K5rji4" h4 pi-.
Contractor hired for work:
Name Lt o-,r4,-j Apto Phone `1
Address
Date for scheduled abandonment_ 7- f o�
The septic system at the above address has be abandoned according to Title V
specifications.
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Signature of Contractor
Method of septic tank abandonment(check one). O removal O sandfill crush
other
Name of Offal Hauler 56W t cf, P(A M P VILA 1.,� C.) ,
This form must be returned to the North Andover Board of Health.
PLEASE DO NOT WRITE IN THE SPACE BELOW FOR HEALTH
7ATIVE S USE O3D#ae
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Ins ecting Agent :2Z �-�05
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8` Town of North Andover
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COMM I DEVELOPMENT AND SERVICES �^ \ •� \
400 Os� Street • orth Andover,Massachusetts Ol 845
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SERVICE PUMPING & DRAIN CO., INC.
5 HALLBERG PARK ARRIVE/
NORTH READING, MASSACHUSETTS 01864 DEPA T `
(978) 276- 0217 • (781) 245-7576 • (978) 774-6284
1-800-794-9265 • FAX (978) 276-0548 DAT F,�aB
PML www.servicepumpingdrain.com HOME PHONE
WORK PHONE
BILL NAMEJ f J #
/J 1 JOB NAME
BILL ADDRESS S A7 f JOB ADDRESS
❑EMERGENCY WORK
PROBLEM LOCATION ❑LEFTSIDE MAINTENANCE
ElINSIDE [IOUTSIDE ❑FRONT ElREAR RIGHTSIDE ❑DRIVEWAY ❑SUB CONTRACT 1
QN WORK REQUESTED PRICE AMOUNT
GREASE TRAP: gals.disposed
SEPTIC TANK: /) gals.disposed
CESSPOOL: (r/ gals.disposed
PUMP CHAMBER: gals.disposed
SEWER MANHOLE:
gals.disposed
,y
HOLDING TANK: gals.disposed
SAND TRAP: gals.disposed
STORM DRAIN:
DIGGING:
TREATMENT:
INSPECTION:
WATER JET:
DRAIN CLEANING:
TRUCK
# TECHNICIAN HOURS RATE AMOUNT TOTAL MATERIALS
fl-JJ TOTAL LABOR
WORK ORDERED BY
TAX
PO# '4 `Thank`Ybu TOTAL
SG NATu RE:(thereby admov06clge the satisfactory completion of the above described work.)
8228
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