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BOARD OF HEALTH
146 MAIN STREET
TELEPHONE# (508) 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
Y- c
130 , 6(?96
Contractor hired for work:
Name_
Address
Phone 4-% 5
Date for scheduled abandonment /0 115196
The septic system at the above address has been abandoned according to
Title V specifications.
Signatur of Contractor
Method of septic tank abandonment (check one). () removal () sandfill
V) crush ( ) other
Name of Offal Hauler 13,
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