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BOX 20
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r Different location may require su�niUA of proposal Pram licensed professional{_ = engineer =,V
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Prapoeal approved �$h ,g }Ptoposal Disapproved
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Proposal approved with the .followin ` o�nditions ": }r,s ``
.1.::: Procurement of any Town' permit, ..if applicable.
2: Suim ssion of -as built. repair,, sketch in duplicate showing:
a._ Owner's ' name
Street ,IJc'u[te,• :Zbam and Tax .Map number.
c: }:location . of installed F vaaponensied too fixed points muse - .corners) .
^. concrete' is tank, three eaast 6 �h�m.'X.b &
System.description:.(e.g., 1250'gal. ept' pr • '
d. by. :, one f drywells; surrounde oot +gravel) ;
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a 3. System ` rej*r to be performed ifi accordanc , with the above proposal and conditions.
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as< owner; or .reported agent :of owner agree.' the above conditions.
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MAILING ADDRESS 7A A8$" cLosc ScAt2sbA LE, IVY !oslR3
PERSON INTERVIEWED PM Canplaint #
Name & Relationship (i.e, owner,tenant, etc.)
TYPE FACILITY
TOZIMMana All
9�y_sa�- a37�
Proposal (include sketch locating all adjacent wells):
NME: 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.
� : $ -tic l�U �J�NG ST12EET
Proposal approved
's Signaturd' &
Proposal Disapproved
I
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 components 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, or reported agent of owner agree to the above conditions.
SIGNATURE TITLE DATE 10/ 0 / o
TIM WAte (PCID); Yellow Ot�n ffi); Pink (Anija3nt)