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BOARD OF HEALTH
120 MAIN STREET
NORTH ANDOVER, MASS. 01845
APPLICATION FOR ABANDONMENT
OF SUBSURFACE DISPOSAL SYSTEM
(SEPTIC SYSTEM)
PURSUANT TO SECTION 310 CMR 15.354
OF THE STATE ENVIRONMENTAL CODE, TITLE V
TEL. 682-6483
Ext23
This form must be submitted to the Board of Health no less than
five (5) days prior to date of abandonment and be accompanied with
a copy of the sewer connection permit.
Name
Phone
Address
J. %rc��►rG
OContractor
hired for work:
Name
L,�� ���
Phone
Address
Date for scheduled
abandonment
-7 :e
Method of
septic tank abandonment
(check one).
( ) removal
( ) sandfill (
) crush
( ) other (describe
below)
Other
PLEASE DO NOT WRITE
IN THE SPACE
BELOW
FOR HEALTH AGENT'S USE ONLY
11�L
Ins tin
A nt
Date
Comments
x
1121
APPLICATION FOR SEWER SERVICE CONNECTION
North Andover, Mass. Lf 19_(2_
Application by the undersigned is hereby made to connect with the town sewer main in t '� ��� Street,
subject to the rules and regulations of the Division ofPublicWorks.
The premises are known as No. U'f� So G��Street
or subdivision lot no
Owner
l
`lV
Contractor
Address
C-0 ISG -'21/A-770/ G
PERMIT TO CONNECT WITH SEWER MAIN
The Division of Public Works hereby grants permission to
to make a connection with the sewer main at
subject to the rules and regulations of the Division of Public Works..
Inspected by
Date
0
By
See back for rules and regulations
j
Street
Division of Public Works