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BOX 24
02817
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138
OWNER'S NAME- -t C,-A 44,,k Mnt Plick 5.211,-�
SITE LOCATION
MAILING ADDRESS
PERSON INTERVIEWED
PCHD Complaint
Name & Relationship (i.e,'ow!6k,bE6aht-'etc.)1
DATE -4
-.T-YPg,FACILITY,
PROPOSED INSTALLER 4v �e PHONE
74?Z,
Proposal (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 engineqr.or
registered architect.
t
Pr;
approved Proposal Disapproved
J VY�
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Inspectorls-Sig &( Title ok-- to
Proposal 4
0�-4 -9-AeAA
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 61 diam. x 61 deep
drywalls surrounded by one foot + gravel),
6. Installer's name and number.
r to be performed in adi'! with the above proposal and conditions.
�Ystqm repair
I, As owner, or ported aJ'AWit`.7,-.6`f owner-agree to the above conditions..
SIGNATURE TITLE #3734 DATE
PM: WAte (PAD); Yellow Mm BI); Pink (Appliamt) /1' 7