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Pti!'NAM QO[lM'Y HEALTH DEPARMENT
DIVISION OF ENVIRUWMML HEALTH SERVICES - 00
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SIIw4GE DISPEL SYSiEK
OHM'S NAME R o L4 PHONE � 9 � � �' - ,fie S-3
SITE LOCATION P V d 0/ J,(-,
MAILING ADDRESS W `r N,4 " \ E A L L4 ,
PERSON INTERVIEW-ID PCHD Complaint #
J / Name & Relationship U.e, owner tenant, etc.)
DATE l e o / ,0 o - - - TYPE FACILITY PC. s-
P.Aaef r-
PHONE
REGISTRATION # (
1 (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.
_ LS-1 R E,DLA-G F> x sue'/ 6 S' 61 C C I-;a- M/<
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C, t4- el r- E4,1 s7-/W-6 P-ee,(,05 4Q&11L — 1V—CC
�J �J A-1 ANa 4 A( No C LoS A-
Proposal approved Proposal Disapproved
Inspector's Signature & Title QAtt
Proposal approved with the following conditions:
1. Procurement of any Town pest 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 camponents tied to two fixed points (e.g.,house corners).
d. System description (e.g., 1250 gal. concrete septic tank, three precast 6' diam. x 6' deep
drywells 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, r reported agent of owner agree to the above conditions.
SIGNATURE L137I TITLE JJ CC," d- DATE
.: V&te (PAD); YeUcw (fin ffi); Pink (klilo nt)
PC -RP 97