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BOX 20
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02333
OWNEI
SITE
MAIL:
PERSON INTERVIEWED /.E'�srrrriS *-1LaJfJ Yer,1041 Pao Carplaint #
Name & Relationship (i.e, owner,tenant, etc.)
DAZE TYPE FACILITY
PROPOSED IISSTM FR PRONE
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 fran licensed professional engineer or
registereVr Itect.
�,v . - /N SA.
Proposal app,�ev�d L Proposal Disapproved
,�A,//Amo 14D
's Signature & Title
r000sal atmroved 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 + graven.).
e. Installer's name and number.
z
tate
(e.g. house corners).
three precast 6' diam. x 6' deep
3. System repair to be performed in accordance with the above proposal and conditions.
I, as owner, or reported gQent o �agree to the above conditions.
SIGNATURE �"� -�*� ✓�-� TITLE
CPM: Mite MV; Yellc w CT, ED; Pink (Appl.i,cant)
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