HomeMy WebLinkAboutApplication for Abandonment - Miscellaneous - 1620 TURNPIKE STREET 1/13/2020 •
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BOARD OF HEALTH
120 Main Street
North Andover,MA 01845
978-688-9540
APPLICATION FOR ABANDONMENT
OF SUBSURFACE DISPOSAL SYSTEM
(SEPTIC SYSTEM
Pursuant to Section 310 CMR 15.354
Of the State Environmental Code, Title V
Name \e cu Phone
Address
Contractor hired for work:
�Name :": Po'ct ko Phone L 9 - S L-)-s
Address V71( ESc- "- 5�- e (�c:
Date for scheduled abandonment
The tic syste t the above address has been abandoned according to Title V specifications.
ignature 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 REPRESENTATIVES ONLY
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Inspect' Agent / Date