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Different location may require suhnittai oL proposal rram licensea pro=essiona.L a g-Li r.L vL
registered arXitect.
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's Signature & Title
Proposal Disapproved
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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 components 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.
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 [ J Y i 1`7fil / TITLE Off% �J eL DATE 4. lqi
OMS: %bite (MD); Yetlaw (fin BI); Pink (Ani im t)
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Name & Relationship (i.e, owner,tenant, etc.)
TYPE FACILITY
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PHCNE
Proposal (include sketch locating all adjacent wells):
NOri'E: 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
Title
Proposal Disapproved
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_Proposal 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.,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 performed in accordance with the above proposal and conditions.
I, as owner, or reported agent of owner agree to the conditions.
SIGNATURE Gw�i� , T MATE- 020�� -��
IPI6: White (PCHD); )M lAw MyAn ffi); Pink Lk#icw t)
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Name & Relationship (i.e, owner,tenant, etc.)
DATE TYPE FACILITY
PHONE
PROPOSED INSTALLER
Pro (include sketch locating all adjacent wells):
Nam: 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 architec . /
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Proposal approved Proposal Disapproved
with the following conditions:
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1. Procurement of any avwn p@LIILLL, .LL %JVJ6.L% ALJJ.11 •
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.,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.
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. n
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IGNATURE U ` �� TITLE DATE (5
V&te (PAD); W11CW M3n BE); Pink Qa2jj ent)
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