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00943
OWNER'S NAME
PROPOSAL FOR SEWAGE DISPOSAL SYSTEM REPAIR
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PHONE
2- 7� -763a
SITE IDMTION ;611 t.,, &— -f,dr� tom, _
MAILING ADDRESS
PERSON INTERVIEWED PAID Canplaint #
Name & Relationship (i.e, owner tenant, etc.) n
DATE TYPE FACILITY
PROPOSED INSTALLER 621•�Z Cc' PHONE L711
REGISTRATION #
Pro (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 fran licensed professional engineer or
registered architect.
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Proposal approved t%n``, Proposal Disapproved
Inspector's Signature & Title
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Proposal 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 components 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 agent of owner agree to the above conditions.
SIGNATURE d z� TITLE `\ _ DATE
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