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SITE WMTION 1102 45 6 CDIf,Ci'17.hu,s I Y -\Ie FA-To V8t 1 4y 'Il"I# _J o; ,31 I'S ' l
MAILING ADDRESS .S 1�-/y1 °� /05779
PERSON INTERVIEWED PCHD Complaint #
Name & Relationship (i.e, owner,tenant, etc.)
DATE TYPE FACILITY
PHONE J el J5- 22iS
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. nn <
-Ai n 4 �.S' yS 7'��&795 -
Proposal approved
Inspector's Signature El Title
Proposal Disapproved
A
Proposal approved with the following conditions:
1. Procurement of any Town permit, if applicable.
#; 2.. Submission of as built repair sketch in duplicate showings
A. Owner's name.
b. Site Street Name, Town and Tax Map number. .
c. Location of installed canponents tied to two fixed points (e.g.,house,corners).
d. System description (e.g., 1250 gal. concrete septic tank, three precast 6' diam. x 6' deep
drywlells surrounded by one foot + gravel).
e. Installer's name and number.
3. System repair to be perfon ed in accordance with the above proposal and conditions.
I, as owner, o reported agent of owner agree to the above conditions.
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31?IES: 6►izi (PAD); YeUc w (fin ffi); Pink (k#jm t)
Ute
Proposal approved with the following conditions:
1. Procurement of any Town permit, if applicable.
#; 2.. Submission of as built repair sketch in duplicate showings
A. Owner's name.
b. Site Street Name, Town and Tax Map number. .
c. Location of installed canponents tied to two fixed points (e.g.,house,corners).
d. System description (e.g., 1250 gal. concrete septic tank, three precast 6' diam. x 6' deep
drywlells surrounded by one foot + gravel).
e. Installer's name and number.
3. System repair to be perfon ed in accordance with the above proposal and conditions.
I, as owner, o reported agent of owner agree to the above conditions.
-
rti:. ... - .: n. ... ,. .v, r: a ,....: r. +.._. r•....n.. ..» _ .ar,.ri' -b _ .. .•, _
_ 11,x- .... _..�......... DAs....
31?IES: 6►izi (PAD); YeUc w (fin ffi); Pink (k#jm t)