HomeMy WebLinkAbout- Application - 12/13/2018 Axe)
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BOARD OI+'HEALTH
120 :Main Street j
North Andover,NSA 01845
978-688-9540
A.PP1,ICA7I0N FOR ABANDONMENT
OF SUBSURFACE DISPOSAL SYSTEM
(SEPTIC SYSTEM)
Pursuant to Section 310 CMR 15.354
Of'the State Environmental Code, Title V
Name ,/" l / lZ`/"/C��� Phone
.Address -7 o
Contractor hired for*work:
Name f It !f � Q " p�Cc�C PhonetS` -
Address
Date for scheduled abandonment ��� �,/ � 7 0 Xe d
p system at the address has bePA11 bar Boned according to Title V specifications.
The septic s above -�'
Signature of Contractor, „w
Method of septic tank abandonment(check one). ( ) removal ( ) sandlill crush ( ) other
n
Name of Offal Hauler °°
T his farm most be returned to the North.Andover Board of`Health.
PLEASE DO NOT WRITE IN THE SPACE BELOW
FOR HEALTH REPRESENTATIVES ONLY
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