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. s � 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. l Inspecting Agent Dat