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BOX 11
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01032
PI imm axwyH,FALTH D.E. PARmw
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
225*-0310
SYSTEM REPAIR PROPOSAL, OR:
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1-730.
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OWMIS lam PHONE
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ITE LOCATION 's I/Vmv
MAILING ADDRESS Plfile-R WU /L%/
PERSON IL tMUEWED MM Complaint #
Name .& Relati6nst4p (i.e,, owner, tenant, etc.) -
DATE TYPE FACILITY
PROPOSED INSTALLER PHONE
Proposal (include sketch locating'all adjacent wells):
NOTE:' .' Pepair must be, in, same - location And of 'same type as original sewage disposal system.
.
Different, location may require submittal of Proposal from li,censed.professional'engineer'or
registered architect.
ftoposa,l Proposal Disapproved
. -------
'Inspector's,'Signature Title Date
.Proposal approved.with the following conditions:
1. Procufement of any Town pemit, if applicaKe.
2. Submission of as built repair sketch in duplicate showing:
a. owner's name.
b. Site streetName, Town and Tax Map number.,
.c Iom lon'of installed caqD6fiepts tied t6 two fixed points (e.g.,hou4d corners).
6
d. SystOm"description. (e.g., 1250 gal. concrete septic tank, three precast 61 diam. x 61 deep
drywdlls surrounded by one foot + gravel).
e. Installer's name and number.
3. System repair to be perfc;nned in accordance with the above proposal and conditions.
I,, as LMULM UL t of owner agree to the above conditions
SIGNATURE17 7 TITLE —DATE
MM: V&te (PCHD); YeUcw (inn BE); Pink (Aniiamt).
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