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BOX 25
IN IN
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02959
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tUMAM COUNTY HEALTH DElARTMENr
DIVISION OF ENVIRONKEN L HEALTH SERVICES
PROPOSAL FOR S39= DISPO614L SYSTEM REPAIIt a'
OWNER'S NAME D 0 A! 4, V 0 a DV A/f t KI A•2OO PHONE
SITE IDCATION ko l-, rr S' T0 k; ,P , ?
MAILING ADDRESS_ U-1- 4'� W- UA- L L
PERSON IlWTERVIEiWID PCHD Complaint #
Name & Relationship (i.e, owner,tenant, etc.)
DATE Z CI TYPE FACILITY � �� r .'� � � /! 2 r►'1
PImPO6ID jjilSTAr.r F R !P./4' PHONE S 4 —d S'
REGISTRATION #
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 engineer or
registered architect. „
5 � C 2
To mo
& T
Proposal Disapproved
Da
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 cagments tied to two fixed points (e.g.,house oorners).
d. System description (e.g., 1250 gal. concrete septic tank, three precast 6' diem. x 6' sleep
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.
It as owner, or reported agent of.owner agree to the above conditions.
SIGNk URE TITLE X 6 ew .r DATE ! 2 S
C{P16: Mite MM Yellow (awn ED; Pink Ualiaant)
PC -RP 97