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DOMINICK PANGALLO MAYOR CITY OF SALEM, MASSACHUSETTS BOARD OF HEALTH 98 WASHINGTON STREET, 3RD FLOOR SALEM, MA 01970 TEL. (978) 741-1800 [EMAIL REDACTED] DAVID GREENBAUM, RS, CHO HEALTH AGENT Application for Abandonment of Subsurface Disposal System Fee: $50.00 I, apply for a permit to abandon the Sub-surface sewage disposal system located Name of licensed drain Phone Number: If tank needs emptying, name of septage (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: Signed: (owner/applicant) FOR OFFICIAL USE ONLY Amount received: Date Witnessed