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BOX 11
01128
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01128
o*=, s NAME
SITE IDCATION
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PM CaVlaint #
Name & Relationship (.e, owner,tenant, etc.)
DM TYPE FACILITY
PROPOM TiQRTA A F:R� ti) EA L PH= J &•3 - 2 6 3 ' 2 V07
REGISTRATION # 7 Tf P �-
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.
s Signature &
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roposal approved with the following conditions:
1. Procurement of any 'foam 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 oaiponents tied to two fixed points (e.g.,house corners).
d. System description (e.g., 1250 gal. concrete septic tank, three precast 6' diam. 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 caner agree to the above conditions.
SIG TI= (iw mr-L DATE —
WM: V&te MD); YeUm (fin BL); Pink ftgiaant)
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