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BOX 17
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01937
P nmm OOT]N'I'Y HEALTH DEPARDOR
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
225 °0310 —;z,
PROPOSAL FOR SEWM DISPOSAL SYSTEM REPAIR
0VNER' S NAME 6 -4 PHONE
SITE LOCATION ; �. C tv� D r 2 �� P,, 4 TO _
MAILING ADDRESS i fL :, ► .2 2 9 Qn fl c -. _ i r-f U
22 -2 9
PERSON INTERVIEWED. _� (Z ; n �% U%,.! �m.�C PCHD Complaint #
Name & Relationship (i.e, owner,tenant, etc.)
DATE] TYPE FpcILITY r r� l2 G
PROPOSED IlSSTALLER 1 Q t o ../ ,�, yc,t or5� C�r� l�r�� PHONE 2.Z S - (o :Z 7 %
Pro (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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Proposal approved
s Signa.Enfe & T
Proposal Disapproved
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 canponents tied to two fixed points
d. System description (e.g., 1250 gal. concrete septic tank,
drywells surrounded by one foot + gravel).
e. Installer's name and number.
s
(e.g.,house corners).
three precast 6' diem. x 6' deep
3. System repair to be performed in accordance with the above proposal and conditions.
I, as own , r reported agent of er agree to the above (nditions.
SIGNATM 0 it,tA TITLE
PIES: Mite MD); Yellow (m ffi); Pink (k i®nt)
PATE Y - 3 %5