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BOX 18
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02062
OMMIS NAME A60 6 � ,e7 PHCHE
SITE LOCATION
MAILING ADDRESS
PERSON INTERVIEWED ip U.er PCHD Complaint #
& Wationsh owneritenant,, etc.)
DAM C, TYPE FACILITY
PROPOSED INSTALLER
.0;�oppsgl (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
k6oiatered architect. - , , I
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Proposal approved_
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3.
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Proposal Disapproved - --
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Submission of as built repair "sketch in duplicate bhowihqt*
A. Owner' 6 kAfte%.
bi Site Street Maine; TbWh And %--X Map M-2-6bir'a
C. Locati6f, of ddfiP6hMt--d- U@Fd to two i ed 06ifits, dah6fa),
Odhdf -td c ---fiki Ufmd- pto-dadt, b' diatn.
System description digzj 12-5 gala d -6 ta
dkYWdild surrounded by one fact + §ft%!)
6. ins-ta-11- 6± i § h&M& AM h
System repair to b6 performed in &dddk&-M* With the Ab&V6 proposal AM 6M&t-46fis .
as owner; or reported Ag6fit df 6wiia aqfi!e t6 the Abdvd dMditi6f1§b
SIG1�1Zi)RE TITLE ---bikT--E
C3P Bs V&be (PM); Yellow dain It kil+i, (4U&i)
x 6' deep
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