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BOX 25
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Name & Relationship (,i.e, owner tenant, etc.)
DATE TYPE FACILITY S % o /z\/3
PROPOSED INSTALLER CA W4?1 PHONE -
Pro (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. �������� ✓N��
Proposal approved
2.
3.
Inspector's Signature
Proposal Disapproved
conditions:
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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' diem.
drywells surrounded by one foot + gravel).
e. Installer's name and number.
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.
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