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HomeMy WebLinkAboutAbandonment of Septic System - Permits - 555 SALEM STREET 4/23/2021 BOARD OF HEALTH �pF�p�cQP Town Hall, 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 CIT4ji Phone Address ,S`YS_ kfn S"T� •A' Contractor hired for work: Name `7D-f+A/ V'1,4 R-c4 Phone e? 7 Y Address 130 /-} ,,, lei --ti TJ . Date for scheduled abandonment The septic system at the above address has been abandoned according to Title V specifications. Signature of Contractor Method of septic tank abandonment (check one). ( ) removal ( ) sandfill (crush ( ) other Name of Offal Hauler C t This form must he returned to the North Andover Board of Health. PLEASE DO NOT WRITE IN THE SPA I-'E BELOW FOR HEALTH REPRESENTATIVES ONLY Inspecti Agent Date n _, y 22®� —��ii(�(�s'�^lr�,� �s,�^��u�^�-'�,�P a�d�'b..+��,-aK�-���:ttn��`-• ti/z s © s 3aa . /��