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BOX 12
I On 14;l m
16
01260
SITE
PERSON INTERVIEWED � F PCHD Cmplaint #
'Nam & Relationship (i.e, ownerttenant, etc.)
DATE TYPE FACILITY
PROPOSED INSTALLER 4� �`CT PHONE
Proposal (include sketch locating all adjacent wells'):
NOTE: Repair must belin 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. .I.
,V, 4V
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00
Proposal approved
Proposal Disapproved
Inspector's Signature &1ritle Date
Proposal approved with the following conditions:
1. Procurement of an permit, if applicable.
2. Subnisqion of as repair sketch in duplicate showing:
a. Owner I s name.
b. Site Street Na#'el',, Town and Tax Map number.
c. Iodation of installed components tied to two�'fixed points (e.g.phouse corners).
d. System descripti6n (e.g., 1250 gal. concrete septic tank,, three precast 61 diem. x 61 deep
drywells surrounded by one foot + gravel). i
e. Installer's name And number.
3. System repair to be'performed in accordance with the above proposal and conditions.
per
I, as owner,, or reported agent of owner agree to the above conditions.
SIGNATURE
TITLE DATE
MUS: HAte MD); YeUcw (Tapin EL); Pink LbVqUamt)
14
JOSEPH MIA
43 ILION RD.
= TAIRFIELD,CT 06812
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72
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pt
13
a-.- rt S,(N,m�
OWNE
SITE
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• �• i� �� lye :Ti�ia:�i��7
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DATE
.. 5. -M!R 4 k, cq 0.1 A IN 5I9
Pam Catiplaint #
! iName & Relationship (i.e, owner,tenant, etc.)
TYPE FACILITY e�
.. � it PHONE / !7
I
1 Proposal (include sketch locating all adjacent wells):
NOTE: Repair must begin same location and of same type as original sewage disposal system.
Different,location may require submittal of proposal fran licensed professional enng e
registered architect.. ,
n i
Proposal approved _.
�I
's Signature & title
Proposal Disapproved
i
Proposal approved with!the following conditions:
1. Procurement of any'Tdwn permit, if applicable.
2. Submission of as built repair sketch in duplicate showing:
a. Owner's name. I'
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
drywiells surrounded by one foot + gravel).
e. Installer's name and number.
3. System repair to be performed in accordance withithe above proposal and conditions.
I, as owner, or reported agent of owner agree to the above conditions.
SIGNATURE j.�, P
�,. TITLE DATE
PTE.'S: V&te MD); Yellow Mbt n BI); Pink