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BOX 23
, , 1
02675
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Rev.'.
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Name & Relationship (ioep ownerptenant, etc.)
DATE « TYPE FACILITY - _d''o,'. ����ar
PROPOSED NSTALLER >`��Gv' Ael" r� ��ii Pik
ftoppsg (include sketch locating all adjacent wells):
NOTE: Repair must be in same location and of same type as original sewage disposal systm.
Different location may require submittal of proposal from licensed professional engineer or
registered arc hitecto
Proposal a Proposal Disapproved
s Signature & Title
Pr000sal anuroved with the following conditions:
to Procurement of any Town permit® if applicable.
2. Submission of as built repair sketch in duplicate showing:
ao Owner's name.
b, Site Street Name® Town and Tax leap number,
c. Location of installed components tied to two fixed points
do System description (e.g., 1250 gale concrete septic tank,
drywells surrounded by one foot ¢ gravel).
eo Installer °s name and number.
Date
(e.g.phouse corners),
three precast 61 diem, x 61 deep
3. System repair to be performed in accordance with the above proposal and conditions.
Ip as owner, or reported a ent of owner agree to the above conditions.',
SIGNUORE TITLE L117Y DATE % % "V "
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