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PERSON INTERVIEWED PCHD Complaint #
Name &Relationship (i.e, owner, tenant, etc.)
DATE TYPE FACILITY
PROPOSED INSTAUM 61-2 PHONE ✓�•�� 7/ 7�
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.
Proposal approved
Inspector's Signature &
Proposal Disapproved
cate 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' diam. x 6' deep
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.
I, as owner, or report agent of to the above conditions.
SIGNATURE TITLE O DATE
MIS: WAte (FAD); Yd1cw (Tan HE); Pink (A AUCEink)