415 LAFAYETTE STREET SEPTIC ABANDONMENT i
{OX-1
CITY OF SALEM MASSACHUSE.TTS 10
Eotkm OF HE_-�LTH
98 W ASHINGTON STREET,3m FL OC E I V E D PPubhcH Promote.ealth
TEL. (978) 741-1800
KIMBERLEY DRISCOLL health@salem.com
MAYOR AUG ]. $ 2021 DAvID GRF.rI�isAVM
HT�LTI-I AGENT
CITY OF SALEM
BOARD OF HEALTH
Application for Abandonment of Subsurface
Dis stem
Fee: $50.00 CL
q
I, 5�� Cp / � � herewith apply for a permit to abandon the
Sub-surface sewage disposal system located at
Name of licensed drain layer:
Phone Number: 9 7 7 V 1 — 4
If tank needs emptying, name of septage hauler: ,S'�N�lc cs na,p t oi-o
(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: /zzz
Signed:
(owner/applicant)
FOR OFFICIAL USE ONLY
Amount received: By:
Date abandoned: Witnessed by: