85 MEMORIAL DRIVE - ABANDONMENT OF SUBSURFACE DISPOSAL SYSTEM b �1
CITY OF SALEM, MASSACHUSETTS
BOARD OF HEALTH
98 WASHINGTON STREET,3RD FLOOR Public Health
SALEM,MA 01970 Prevent.Promote.Protect.
DOMINICK PANGALLO TEL. (978) 741-1800
MAYOR health(a salem.com DAVID GREENBAUM,RS,CHO
HEALTH AGENT
Application for Abandonment of Subsurface
Disposal SN stem
Fee: $50.00
1, Apex Abatement and Demolition LLC herewith apply for a permit to abandon the
Sub-surface sewage disposal system located at 85 Memorial Drive Salem MA
Name of licensed drain layer:Apex Abatement and Demolition LLC to crush and fill tank
Phone Number: 617-733-4211
If tank needs emptying, name of septage hauler:Stewarts Septic Services
(Septage hauler must be licensed by the Salem Board of Health, copy of the Pumping record has to be provided
at time of abandonment)
Date: 4/27/26
Signed:
(owner/applicant)
FOR OFFICIAL USE ONLY
Amount received: By:_
Date abandoned: S 7 2(o Witnessed by-
(978Y 372-7471 (978)475.2593 (603)772.5548 (978)452-"22
58 Sorit1.: N"imball Street, Rradford, MA 01003.5
e f I --PAY FROM THIS BILL
Cu omen ame: ❑ Reg. Nature of Service
O N1C Reg.Maint,
Service Location: 1l ;�5
�— ❑ mergency
Phone:
Septic Tank Pumping and Cleaning J�ay ❑ Night
"Done the Right Way"
Contact:
Billing Address: Not Responsible for Covers
or Irrigation Systems
Ci Zip:
Special Instructions Completed
❑ Incompleted Reason:
Per
AM
Services Rendered
Vacuum Pumping Observations Drain Cleaning
XSeptic Tank efi> ❑ Main Line
O Drywall 0 Leechfield Runback O Toilet Bowl 1
_ ❑ Leech Pit/Overflow O Riding High ❑ Kitchen Sink
O;D-Box ,� (liquid level) ❑ Bathtub/Shower
❑ Pump Chamber ❑ Full to Cover ❑ Vanity I
❑ Grease*ap ❑ Excessive Solids ❑ Floor Drain
❑ Catci,ilAin Top/Bottom O vent
❑ Portable Toilet O Use No Powdered Soap ❑.Sewer Jet
D Other O Heavy Grease ❑ Other
Oty oots Footage:
Size: O Suggest Electric
❑ Under 1000 gallons ❑ 1000 gallonSA1500 gallons Rootering
❑ 2000 gallons ❑ 3000 gallons ❑ 4000 gallons ❑ Van Called
❑ 5000 gallons ❑ Other O Other
Misc.
❑ Digging Charge + O Backhoe ❑ Inspection
❑ Location ❑ Consultion bn'' ❑ Certification: P/F
❑ Service Call ❑ Estimate Reason:
O Labor ❑ Portable Toilet Rental ❑Pump Repair
O Waiting Time ❑ Baffle ❑ Repair
* Digging Charge is Per Driver O Chemical Treatment
Discretion ❑ Other
Description of work /--rkpy,
Recommendations Terms of Payment
Parts
Vacuum Pumping Drain Cleaning PAYMENT DUE IN FULL
Yr. Month Yr. Month UPON COMPLETION Tax
Terms&Conditions ❑ Cash ❑ Check ❑Credit Discount
Total �
1. Not responsible for damage beyond curb fine. 3. 1.5°k per month will be charged to accounts past due.
2. All complaints shall be reported within 48 hours. R.The purchaser agrees to pay all cost of collection.
Customer Signature Serviceman
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