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REGISTRATION #
o�a1 �fiddle sketch IOMUnq aU adjwant Wails):
=at be in an loaation &M of Mar type al arigina3. sMaya . pqi systam.
Diffemt: lm den may rgdre wArdtW of prgpoaal fr m lieu aad pcoft*ioMI engimer ar
ngistered architect.
with the ftUcwi= O di
11 FXQOUUWt-CC OW TOM POWite -it GRAUSUG..
Z. & tissicn of as bent r9air al ketch In 0*11aato shows
a. Omar 's Hama.
b. site Viset'v o of Town sad Tax Mbp mubar.
c. i+ooatian of ineta Ued cwponants tied to tro fixed points ts.q.,how corrarq.
d. 8�yataen �r �ecs�►.gone � + � �� `'�' taw p�eout 6' 41am. x a' asst
S. Installer's --A tax"r.
J. Systra repair to be perfo=d in acCOrdaao• with the abM porapogl and aoaditioas.
I. ss agar, or repoa w agent of smear Was to the abose aooditioaa. 9 �J
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DIVISION OF ENVIRONMENM HEALTH SERVICES
PROPOSAL FUR SEWAGE DISPOSAL SYSTEK REPAIR
OWNER'S NAME 6-- ra e,- -e 17� ec $ o� PHONE F/
SITE LOCATION -S--5" Ti
MAILING ADDRESS
PERSON INTERVI30) Pty Camplaint # /z�✓�<
Name & Relationship (ice, ewner,tenant, etc.)
DATE TYPE FACILITY
PROPOSED SSTAdER, --- «�'� �� PHONE
REGISTRATION #
(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.
V(
eAle"
Proposal Disapproved
6 - G/�
DI! e
proposal approved with the following conditions:
to Procurement of any Town permit, if applicable.
20 Submission of as built repair sketch in duplicate shcwinge
as Owner Is name.
bo Site Street Name, Town and Tax Map number.
co Location of installed components tied to two fixed paints (eogo,heuse corners).
do System description (e.g., 1250 gal. concrete septic tank, three precast 61 diamo x 60 deep
drywells surrounded by one foot ¢ gravel).
eo Installer's name and numbers
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.
SIGNATURE /"f e o
}Ply: Vibe MD),-, YeUco (Tan BI); Pink (ARl.iamt)
DATE