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BOX 12
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No
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01254
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OWNER'S NAME
SITE LOCATION
MAILING ADDRESS
TO
•Z- 7�-�(-y77
PERSON INTERVIEWED PCHD Camplaint #
/! Z r/ r Name & Relationship (i.e, owner,tenant, etc.)
DATE / i . TYPE FACILITY
h,,• 16.1�+�7
PHONE �L:2 � PT- 6-z
REGISTRATION # V''
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
's Signature &
Proposal Disapproved
toposal 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 components tied to two fixed points (e.g.,hozse corners).
d. System description (e.g., 1250 gal. concrete 'septic tank, three precast 6' diam. x 6' deep
drywalls 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 f TITLE 42 DATE Ll d
CPW: (White (FAD); YeUcw ( ): Pink (AWlicant)