HomeMy WebLinkAboutMiscellaneous - 191 Andover Bypass (2) '— 191 Andover Bypass
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BOARD OF HEALTH
146 MAIN STREET SEP 'j, 0
TELEPHONE# (508) 688-9540
APPLICA TION FOR ABANDONMENT
OF SUBSURFACE DISPOSAL SYSTa1 �W �:3ja6
(SEPTIC SYS TEV)
Pursuant to Section. 310 CMR 15.354
of the State Environmental Code, Title V
Name
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Address /2 / /4 ki Z vQ/
Contractor hired.f or work:
Name e I e K �!�� Phone 60 - 7774-
Address
0 7774-
Address T?o 1 b c (�rr( `S
Date for scheduled abandonment `� /-z 9 C
The septic system at the above addr has b bandoned according to
Title V specifications.
Signature of Contractor
Method of septic tank abandonment (check one). ( ) removal ( ) sandfill
crush ( ) other
Name of Offal Hauler oil
This form must be returned to the North Andover Board of Health.
PLEASE DO NOT WRITE IN THE SPACE BELOW FOR HEALTH
REPRESENTATIVE'S USE ONLY.
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Inspecting Agent Date
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