HomeMy WebLinkAboutMiscellaneous - 695 SALEM STREET 4/30/2018 (2) 695 SALEM STREET - C� -
210/065.0-0041-0000.0
WER
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T(3V N O ,
AR" O
BOARD OI- I-IEALAII JUN 1 9 1997
146 .MAIN STREET
TELEPIiONE9 (508) 688-9540
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APPLIr_A LION FOR .4BAND(J.`'V LVT �w��✓
OF SUBSr:1Y-ACE DISPOSAL SYS T,'A,/
/SEPTIC SYSTEv)
Pursuant to Section 310 CMP 13.334
of the State Environmental Code, Title V
Name MI . Phone
Address i- 6-q57 S,ft`e-p-� ` F Ic-
Contractor (tired for work:
Name �r �� ��� Phone
Address IJV7 t/el —_–
Date for scheduled abandonment �� 7
t
The septic system at the above address has b abandoned according to
Title V specifications.
Signature o ractor
I
thod of septic tank abandonment (check one). ( } removal O sandfill
crush O other
Name of Offal Hauler �j
This form must he returned to the North Andover Board of Health.
PLEASE DO NOT WRITE IN THE SPACE BELOW FOR HEALTH
REPRESENTATIVE'S USE ONLY.
-/7
Inspecting Agent Date
p-,DOVER/
ROS PC OF
BOARD 01-- i E,�I_. r E I I JUN t 9 1991
146 AIN STREE-r
TELEPHONE# (508) 688-9540
w✓
APPL ICA 1'10.V FOR ABA,VT-V%MLV1 �w
OF SUBSC,RI`:-iCE DISPOSAL SYSTEA4
ASEPTIC SYSTaf/
Pursuant to Section 310 CMR 15.3j4
of the State Environmental Code, Title V
Name All . C.-1-�a560/d Phone
Address 451 ; �y
Contractor hired for work:
Name 4cq W Phone
Address n t/zl
Date for scheduled abandonment /ZOA?
The septic system at the above address has b abandoned according to
Title V specifications.
Signature o ractor
jethod of septic tank abandonment (check one). O removal O sandfill
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.
Ill t� -/7
Inspecting Agent Date