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BOX 12
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OWNER'S NAM At.
PHONd�O'SS// gib
SITE LOCATION /ZC/ AN7Y*_/- 5nAi 2 m# .
MAILING AboRms
PERSON nMMnEWM QVIV48-r. Pam Caiplaint #
-Name & Relationship (i.e,, gwneritenantr etc.)
DATE 7S1- 0/2 TYPE FACILITY
7
PROPOSED nsmmm fre c/, ^7 C -
PHONE ;- 3,73
REGISTRATION #
Proposal (include sketch- locating all adjacent wells):
Repair must be" in same location and of same type as original sewage disposal system.
Dif ferent�' location may require submittal of proposal from licensed professiohal engineer or ,
registered architect. A/C I . .:1.
'V
-7 JN ;FdtlmrbrS
--7 S
Proposal. approved Proposal Disapproved
Inspector!s Signature &.Title
Proposal with the following conditions:
ipproved
1. Procurement of any Town pexmtr if applicable.
2. Submission of as built repair sketch in duplicate showing:
a.: Owner's ,naMe,.1';,
b. 'Site Street.` Nate Town and Tax Map number..
c... Location of.4iristalled.6caipionents tied to ;two fixed points
(e.g.,house corners)'
d.'Syftem description ,,(e.-q.'r,-1250 gal. concrete septic tank,
three precast 61 diam..'x 61
:drywells surrounded by one foot.+ gravel)i'o
e. Installerls' name `and number.
3. Syttekh;repair -to be performed in accordance with the above proposal and conditions*
I, as own . erl or ,reported-agent.of owner agree to the above conditions.
"Si OZ
DATE
3,
W-d Mib);, YeUcw Mbn BI) - Pink Lbqlian7t)
PC-RP: 7'1"
.9
..... . .. . .......
SITE I�a°�TIOE
r
MUCLING ADDRESS
PEW30H d w n!e-r PCB ccwlaint 0
Name & Relationship (i.e;, owner,tenant, etc.)
DATE -7 _- ? ` 91 .� TYPE FACILITY
PHMM L9_9 3733
REGISTRATION #
Proposal (include sketch locating all adjacent wells):
Nis Repair must be in same location and of same type as original swage disposal systM.
Different location may require submittal of proposal from licensed professianal �enginew or
tie
isred architect. t q / C: ca,, ( ,"J c;% lo:
Proposal approved
�' Inspector ° s Signature & Title
k
Ci
///oDate
,roposal aoproved with the following conditions
to Procurement of any Torn permit, if applicable.
20 Submission of as built repair sketch in duplicate showing:
ao Owner °s name
bo Site Stmt Name, Town and Tax Map number,
co Iiacation of installed colponents tied to two fixed points (eogo,house corners).
do System description (e.g.# 1250 gale concrete septic tank, three precast 60 dim. x 60 ftap
drywells surrounded by one foot ¢ gravel).
ea Installer's name and number.
3. System repair to be performed in accordance with the above propel and conditions.
I, as owner, or rtad agent of owner agree to the above conditions.
Oho White MD); Yellai (fin M)8 Pink Ukaliamt)
PC -RP 97
AM' c�G.....
a. .e PUIi m a Rm HEALTH DEPAirmw
- DIVIISION ,.OF 'ENVIRONMENTAL. HEALTH SERVICES
Q18
F PROPOSAL FOR SEWAGE DISPOSAL SYSTEM REPAIR v
NER'S NAME'' OL4 . e- PHa
TE LOCATION L/3 (X r A
ILM ADDRESS
RSON . n?BWIEWE D Q w ,� P_ r' PM complaint ,
Name & Relationship (i.e, owner tenant, etc.)
7. "S" TYPE FACILITY
6PWED . `INSTALLER rr2 /S�Ci9�►,_ S Ptiow
:GISTRATION #.
.(include sketch locating all adjacent wells):
M:'`..Repair must be in same location and of same type as original sewage disposal system.
.fferent, location may require submittal of proposal fram licensed professional engineer or
xgistered architect. 1
T NS to l/ %Ule w �' l , N so "t, P /��af G� AS 40/.
x: % ZN t ; l T faTor-C
,k'P•S
opoBal approved - Proposal Disapproved .
Inspector's Signature & Title te,
:oposal approved with the'follcwing conditions:
L. Procurement of. any Town permit, if. applicab el .
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 oonditions
as owner, or eported agent of owner agree to the above conditions.
LGNAT{A2E L +C -c� o. r TITLE /)Z w C DATE . *7
E5: Wiibe (PCB); Yellcw Mun' ffi); Pink (A pli®nt) °`