HomeMy WebLinkAboutJ. Hockman, Inc. - 12/31/2020-4q'� -Ti-
Town of Mansfield
Town of Mansfield - Board of Health 6 Park Row
NOV Mansfield, MA 02048
Disposal Works Installer Application
LICENSE NUMBER: J ,
APPLICANT: jAS0 A)
BUSINESS NAME:
MAIL ADDRESS:
CITY/TOWN: �' D /� / l &K STATE: AI ZIP CODE: 4-�'O526
BUSINESS PHONE: BUSINESS CELL: _500- 1 .i D 1 Z V V
BUSINESS FAX: (1 as &y FeS�J
E-mail: tou'Yh "ae--(Z_ tA�, CYavr,
Alt E-mail: C h (\; S (n
EDERAL ID/SS NUMBER: Q t� �" q
LICENSE HELD: Town Jd 0
LICENSE HELD: Town _I A )6
LICENSE HELD: Town R mod/ Lf<
Year Licensed
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Year Licensed C5 D d
Year Licensed c9-00 U
I have read 310 CMR 15.00, the State Environmental code; Title 5, Minimum
Requirements for the subsurface Disposal of Sanitary Sewage and the Board of Health
regulation titled "Minimum Standards for the Subsurface Disposal of Sanitary Sewage".
I understand that deviation from them may be cause for revocation of this permit.
Permit Expires December 31 st yearly.
FEE: $ 100.00
SIGNATURE:
DATE: 0
Please make appropriate changes. Sign, date, and enclose check for $100.00 payable to Town of Mansfield.
Mail to: Board of Health, Town of Mansfield, Six Park Row, Mansfield, MA 02048