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BOX 24
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02854
OWNM
SITE
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DATE (411(,2
PROPOSED INSTALLER
FC W complaint #
Name & Relationship (i.e, owner,tenant, etc.)
I TYPE FACILITY
PHONE(�S�i
Pro (include sketch locating all adjacent wells):
MOTE: 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.
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Proposal approved
Inspector's SignKtuj
Proposal Disapproved
Proposal amroved 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 + gravel).
e. Installer's name and bomber.
23
/bate
(e.g.,house corners).
three precast 6' diem. x 6' deep
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.
SIG DATE
DHSS: Mdte (PCHD) • Yel1cw (fin HU Pink (Applicant)