HomeMy WebLinkAboutMiscellaneous - 95 SOUTH BRADFORD STREET 4/30/2018 (3)� N
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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 13.33=1
of the State Environmental Code, Title V
Name CPAP
Address �I
Contractor hired for work:
4.6
Phone
Name✓r✓D �� Phone
Address
Date for scheduled abandonment
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The septic system at the above address has been abandoned according to
Title V specifications.
S,i�riature of Contractor
Method of septic tank abandonment (check one). () removal () sandfill
(� 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 Date
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