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BOX 18
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01977
PROPOSAL FOR SEWAGE DISPOSAL SYSTEM. REPAIR ,Q 46- ._
SITE LOCATION
PHONE ,5_S
�," TO 3 -- / - _57
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MAILING ADDRESS &rte WknaW Alz,2U , Al-
PERSON INTERVIEWED C—LA � Z&v-r04290 PC HD Canplaint #
Name & Relationship (i.e, owner,tenant, etc.)
DATE �-�%� TYPE FACILITY
PROPOSED INSTALLER S PHONE
REGISTRATION #
PrcLposal (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 fram licensed professional engineer or
registered architect.
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Proposal approved Proposal Disapproved
3er ,
Inspectors Signature & Title to
proposal approved with the following conditions:
1. Procurement of any Town permit, if applicable.
2. Submission of as built repair sketch in duplicate shaving:
a. Owner's name.
b. Site Street Name, Town and Tax Map number.
c. Location of installed capponents 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
drywalls 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 agen of owner agree-to the above conditions.
SIGNATURE TITLE DATE
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