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01175
SITE
PHONE
MAILING ADDRESS
PERSON INTERVIEWED PCHD Complaint #
' .Name & Relationshi p (i.e, owner,, tenant, etc.)
DATE /� 7
TYPE FACILITY
..,§ !; •. :X �+•
PHONE
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.
Proposal approved
Inspector's
Proposal Disapproved
34 e
roposal approved with the following conditions:
1. Procurement of any Town 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 ccmponents 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 perfonTed in accordance with the above proposal and conditions.
I, as owner, or reported agent.of owner agree to the above conditions.
SIGNATURE TITLE GATE
CP 1;& Wiibe (MD); Yellow (fin BS); Pink (Ani iaint)
,W
t
Proposal approved
Inspector's
Proposal Disapproved
34 e
roposal approved with the following conditions:
1. Procurement of any Town 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 ccmponents 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 perfonTed in accordance with the above proposal and conditions.
I, as owner, or reported agent.of owner agree to the above conditions.
SIGNATURE TITLE GATE
CP 1;& Wiibe (MD); Yellow (fin BS); Pink (Ani iaint)
07/03/1997 10:25 9142795989 TYNDALL SEPTIC SYSTE PAGE 02
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