23 CEDARCREST AVENUE SEPTIC ABANDONMENT ow�
CITY OF SALEM, MASSACHUSETTS
BOARD OF HEALTH
98 WASHINGTON STREET,3RD FLOOR pllbil�`.HP.A11�
Prevent.Promote.Protect.
TEL. (978) 741-1800
KIMBERLEY DRISCOLL healthy salem.com
DAVID GREENBAL'M
MAYOR HEALTH AGENT
Application for Abandonment of Subsurface
Dis o em 4p
Fee: $50.00 Gu
_ herewith apply for a permit to abandon the
Sub-surface sewage disposal system located at ? k 4:f R/Z
Name of licensed drain layer: %Zr/.1 0422�/VS
Phone Number:
If tank needs emptying,name of septage hauler:
(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�09 O
Signe
t;
( (er/applicant)
FOR OFFICIAL USE ONLY
Amount received: � � /2 _ By:
r
1;
Date abandoned: // Z,Z Witnessed by