HomeMy WebLinkAbout- Miscellaneous - 565 OSGOOD STREET 9/5/2018 6
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�w BOARD OI+HEALTH
120 Main Street
North Andover, MA 01.845
978-688-9540
APPLICATION FOR ABANDONMENT
OF'SUBSURFACE DISPOSAL,S"YSTRAII
(SEPTIC SYSTEM)
Pursuant to Section 310 CMR .15.354
Of the State Emdronmental Code, Title V
Phone , . 7 ,
Name
Address 7a` fir °
Contractor hired for work: �,
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Name Thane
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Address
Date for scheduled abandonment '., e-
The septic system at the above address has been abandoned according to Title V specifications.
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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. 1
PLEASE ASL:DO NOT WRITE IN THE SPACE BELOW
FOR HEALTH REPRE,SENTATIV7,S ON Y
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Ins ect` g Agent Date