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BOX 11
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01131
OWNEE
SITE
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PERSON INTERVIEWED PCFID Complaint # 071-17
Name &.Relationship (i.e, owner,tenant, etc.)
DATE TYPE FACILITY
PROPOSED INSTALLER �O /l le,5_g / dl, Y. PHA
Eli '(1nc1ude" 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 a ov /`'' Proposal Disapproved
InpOedtbr !a Signature & Title Date
Proposal.approved with the.-following conditions:
1; Procurement of any Town pennit, 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 cYmponents 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 J,-ILA TITLE dG✓�
PHS: White (MV; Ye].lraw (fin ED; Pink (Appli®nt)
DATE
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PCHD Complaint #
Name & Relationship (i.e, owner tenant, etc.)
TYPE FACILITY
77 / /riPSo:✓ V' % PHONE 2-? i ' Y.3 S"72-"
YM: Re r must be in same location and of same c (include "sketch locating all adjacent wells):.
p� type as original sewage disposal-system.
Lfferent location may require submittal of proposal fran licensed professional engineer, or
istere3 architect. re,
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Proposal Disapproved
Inspec'tor's Signature & Title- Date
:oposal approved with the following conditions:
L. Procurement of any Town •permit, if applicable..
Z. 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 canponents 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.
L System repair to be performed in accordance with the above proposal and conditions.
, as owner, or reported.agent of owner agree to the above conditions.
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CGNATURE / .�a' ,f� " - TITLE 01,✓164
FS: Mibe (POD); Yellow (mn HE); Pink (Appl. CEint)
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41
Proposal Disapproved
Inspec'tor's Signature & Title- Date
:oposal approved with the following conditions:
L. Procurement of any Town •permit, if applicable..
Z. 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 canponents 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.
L System repair to be performed in accordance with the above proposal and conditions.
, as owner, or reported.agent of owner agree to the above conditions.
r
CGNATURE / .�a' ,f� " - TITLE 01,✓164
FS: Mibe (POD); Yellow (mn HE); Pink (Appl. CEint)
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