HomeMy WebLinkAbout2009DOCUMENT CONVERSION SERVICES PROVIDED BY
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BOX 18
i
02009
SITE
MAIL:
rrAFkMAv .uvlr&nvi.rs.r J
DATE
r%Aw un�piainL
Name & Relationship (i.e, owner,tenant, etc.)
TYPE FACILITY
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 fram licensed professional engineer or
registe ed architect. `
Proposal approved Off— Proposal Disapproved
e
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 fixer] points (e.g.,house corners).
d. System description (e.g., 1250 gal. concrete septic tank, three precast 6' diam. 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, rted agent of owner agree to the above conditions.
SIGMA TITLE DATE
O0PUS: Vbite MM; YeUcw (T:kn BI); Pink (Afpliamt)