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PUMM COMM HEALTH DMAMEW q ��
DIVISION OF ENVIRONMENTAL HEALTH SERVICES I
PROPOSAL FOR SEWAGE DISPOSAL SYSTFM REPAIR
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PCFID CcYnplaint #
Name & Relationship U.e, owner,tenant, etc.)
TYPE FACILITY L
PROPOSED IIZSMUF:R PHONE
REGISTRATION #
Proposal (include sketch locating all-adjacent wells):
NOTE: Repair must be in same location and of same type as original sewage disposal system.
Different location may require submittal of proposal fram licensed professional engineer or
registered architect.
N
Proposal'= aprpvedIx Proposal Disapproved
Inspector's Signature & Title to
'roposal approved with the following conditions:
1. Procurement of any Town permit, if applicable.
2. Submission of as built repair sketch in duplicate showing:
a. Owner's name.
b. Site Street Name, Town.and Tax Map number.
c. Location of installed camponents tied to two fixed points (e.g.,house corners).
d. System description (e.g., 1250 gal. concrete septic tank, three precast 6' diem. x 6' deep
drywells surrounded by one foot + gravel).
e. Installer's name and number.
3. System repair to be performed in accordance with the above proposal and Conditions.
I, as owner, or reported ag t of owner agree to the above conditions.
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PROPOSAL FOR' SEDGE : "DISPOSAL ;SYSTEM REPA
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