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PROPOSAL FOR SEWAGE DISPOSAL SYSTEM REPAIR
OWNER' S NAME al,. -r-9 17C ►; llo - - -- PHONE
SITE LOCATION 1 ! T!►orlas ffd- red Te ow VV, �3"/J�S'63 TO
MAILING ADDRESS»+t•
PERSON INTERVIEWED POND Complaint #
Name & Relationship (i.e, owner,tenant, etc.)
DATE - 6 TYPE ' FACILITY
PROPOSED INSTALLER Q u PHONE
REGISTRATION # L.
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 from licensed professional engineer or
registered architect.
�y Qro0 0- k l - -r R o Id- syir� T,, k
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Inspector's Signature &
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roposal approved with the following conditions:
1. Procurement of any Town pdrmit, 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' &am. x 6' deep
drywalls 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, reported agent of owner agree:to the above.'conditions.
SIGNATURE .TITLE . �� /�/� DATE
OwhS: Wlibe (PCED); Yellow (Ttrlln ED; Pink VW ksnt)