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BOX 17
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01928
SITE
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PHONE 9 P- -31
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PERSON INTERVIEWED PaM Complaint #
Name & Relationship (i.e, owner,, tenazit-,, RZF-. ' )'
DATE TYPE naLIW 0, Q--
PROPOSED INSTAUM -8o ne' -5-eVt1C !AC- PHONE c, 27
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 Proposal Disapproved
Inspector's Signatur 'Titl:. Date/
Proposal approved with the following conditions:
1. Procurement of any'Tbwn 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 (q.g., 1250 gal. concrete septic tank, three precast 61 diam. x 61 deep
drywells surrounded by one foot + gravel).
e. Installer's name and nw�ber.
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
TITLE
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