HomeMy WebLinkAboutApplication for Abandonment of Septic System - Miscellaneous - 1740 TURNPIKE STREET 1/13/2020 • �,'S'r'�IIl�, �
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co` tip��� 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 C, ��Cis Phone
Address ) ?9O T vMQ i K2
Contractor hired for work:
Name A , F PqJlo G �w1`� fin` Phone
Address J 9 L �E5-c" 5' - �a` '"` (' C' C)I °I Li9
Date for scheduled abandonment ZU Z6
The 7sesystem at the above address has been abandoned according to Title V specifications.
Sfgh6ature of Contractor
Method of septic tank abandonment (check one). O removal O sandfill (>q crush O other
Name of Offal Hauler�G �`�t �I$�z l,13ASa�fv�cc.'"
This form must be returned to the North Andover Board of Health.
PLEASE DO NOT WRITE IN THE SPACE BELOW
FOR HEALTH REPRESENTATIVES ONLY
II ,bI-L��
Inspecting ent Date