HomeMy WebLinkAboutMiscellaneous - 120 LACONIA CIRCLE 4/30/2018 (24) Application for Septic Disposal System
Construction Permit— TOWN OF TODAY'S DATE
�'TOR1 �`1TD0`'ER 1�ZA 018 S 254.80—Full Repair
$125.80-Component
Important: Application is hereby made for a permit to:
When filling out
forms on the Construct a new onsite sewage disposal system
computer,use
only the tab key p an❑Repair or replace existingon-site sewage disposal system*
to move your (Kepair or replace an existing system component—What?
cursor-do not p
use the return
key. A. Facility information
_ A dress or Lot#
t ��r''� �i��--r �- ,��• �'��"��� III
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2.-*TYPE OF SEPTIC SYSTEM*:
❑Pump ❑ Gravity(choose one)
**If
POmp system.attach copy of electrical permit to application**;
anventional System(pipe and stone system)
❑ Infiltrator or Biodiffuser(Gravel-Less)(Attach a copy of your certification to Install this type of system.
El Pressure Distribution U.S.(No D-Box)(Attach Draft Maintenance Agreement? RECEIVE-
❑ Pressure Dosed(D-Box Present)S.A.S.
2. Owner Information LEALTH
9 2013
N '� � �
ThI ANDOVER
ARTMENT
AddresCL
if different fromove
ny own State Zip Code
Telephone Number
3. installer Information
me of Company
Ad ess
City/Town � ��,�
State Zip Code
Telephone Number(Celt Phone#it possible please)
4. Designer Information " F
t -7 � � Name of Company ec1" �
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Address
i
CK T - - J� i
Shale / o Zip code � f�� I
Telephone Number(Best#to Reach)
Application for Disposal System Construction permit•page 1 of 2
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