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BOX 11
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064NER'S NAMZeo IaLTre,�z- PHONE
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- & Relationship owner,,tenant, etc.)
DAM TYPE FACILITY
PROPOSED DUIALLER PHONE
REGISTRATION #
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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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 caq=ents tied to two fixed points (e.g. ,house corners) .
d. System description (e.g., 1250 gal. concrete septic tank, three precast 6' dim.
drywells surrounded by one foot + gravel) .
e. Installer's name and number.
System repair to be performed in accordance with the above proposal and conditions.
I, as owner re agent of owner agree to the above conditi
SIGNATURE
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PM: Mite (MV); YeUcw (Mm BT); Pink (Aql. amt.)
PC -;RP 97
x 6' deep