HomeMy WebLinkAboutMiscellaneous - 792 WAVERLY ROAD 4/30/2018 (2)BOARD OF HEALTH
146 MAIN STREET
TELEPHONE# (508) 688-9540
APPLICA TION FOR ABANDONMENT
OF SUBSURFACE DISPOSAL SYSTEM
(SEPTIC SYSTEM)
Pursuant to Section. 310 CMR 13.354
of the State Environmental Code, Title V
Name 1V11 `�j Phone
Address%Y� ve � 1�/
Contractor (tired for work:
Name r P
Address z
pe'. /(,/, '�r
Date for scheduled abandonment
vel'
Phone ( Z 3 '?
The septic system at the above address has been abandoned according to
Title V specifications.
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Signature of ontr ctor
Method of septic tank abandomnent (check one). () removal andfill
( 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.
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Inspecting Agent Dat