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BOX 13
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SITE LOCATION
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PERSON INTERVIEWED Vi o tit AM g.L% CC q1,J l�l V PCHD Complaint
Name & Relationship U.e, owner,tenant, etc.)
DATE A0 L. V cd q - VqQ t TYPE FACILITY PUjj RTF i4 OMh
PROPOSED INSTALLER 1rJ !_U W 1;F]2 ,b LE PHONE
Pro osa.l (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.
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:)ved Proposal Disapproved
's SiVature & Title —'
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Procurement of any Town permit, if applicable. C
Submission of as built repair sketch in duplicate showing:: to
a. owner's name. L16-11— 11
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.
Date
I, as owner, or reported ag t o owner agree to the., above: conditions.__ -_:
SIGNATURE L� TITLE 0— DATE d
U11 1S: Rdte (PAD); Yalcw (fin ffi); Pink UW i®nt)