HomeMy WebLinkAboutAbandoment of Septic System - Miscellaneous - 327 SALEM STREET 7/20/2017 d. I
BOARD OF HEALTH
1600 Osgood Street, Suite 2035
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 Phone
Address 39!� Slf/e�, �` `1),,
Contractor hired for work:
Name�4/1-Z / f, cc e Phone L�
Address 4/bn& ;•,, 4-\ o 2�4, �� `11 I�
Date for scheduled abandonment
The septic system at the above address has been abandoned according to Title V specifications.
ignature of Co actor
Method of septic tank abandonment(check one . ( )r oval (-andfill (-J'c"ru sh ( ) other
Name of Offal Hauler
This form must be returned to the North A dover Board of Health.
PLEASE DO NOT WRITE IN THE SPACE BELOW
FOR HEALTH REPRESENTATIVES ONLY
Inspecting Agent Date
7/20/2017 I M G_0473.J PG
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