HomeMy WebLinkAboutApplication for Abandonment of Septic System - Miscellaneous - 1650 TURNPIKE STREET 1/13/2020 ,PN F N���P� � BOARD OF HEALTH
N�L�N��e 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. 6`k e_cU Phone
Address I l S Tucks �' c�u
Contractor hiredeoc,)
for work:
/
Name � , F w le,.\ vzA G^�- Phone
Address \c� G Gs el- � N , �A� Ma
Date for scheduled abandonment l I Zv2C�
The se system the above address has been abandoned according to Title V specifications.
ture of Contractor
Method of septic tank abandonment(check one). ( )removal ( ) sandfill (yQ 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
�z — 1/10 12,4yw
Inspectin gent Date