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BOX 11
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SITE
PERSON INTERVIEWED PCEID Canplaint #
Name & Relationship (i.e, owner,tenant, etc.)
DATE TYPE FACILITY
PROPOSED INSTALLER 6,S e—b ► l � i PRONE
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 from licensed professional engineer or
registered architect.
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Proposal Disapproved
's Siqnature & Title Ehte
_ cate showing:
a. Owner's name.
b. Site Street Name, Town and Tax Map number.
c. Location of installed canponents tied to two fixed points
d. System description (e.g., 1250 gal. concrete septic tank,
drywalls surrounded by one foot + gravel).
e. Installer's name and number.
(e.g. house corners).
three precast 6' diem. x 6' deep
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 TITLE CJAIFILUC k DATE
OM: Mite MV; YeUcw (� EI); Pink (Applicant)