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03093
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03093
SITE
PERSON INTERVIEWED PAID Complaint #
Nam & Relationship (i.e, owneritenantp etc.)
DATE TYPE FACILITY
PROPOSED INSTALLER IL PHONE
Gf.141
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.
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roposal a:pproved.with the following conditions:
1. Pr6duredent_bf any Tbwn permit, if applicable.
2. Sd6miss4ion 6k as built repair sketch in duplicate showing:,
a. Owner's name.
b. Site � Street . Narte, Town . an d Tax Map number.
C.' 16cation of installed caqmnents tied'to two fixed, points (&.g.,house corners).
d. System-desciiption (e.g.-, 12.50 gal. concrete septic tank, three precast 61 diam. x 61 deep
diywells surrounded by one foot + gravel) .
e. Installer's name and number.
3. System repair- to be perfoYmed. in accordance with. the above ti
proposal and condi ons.
I, as owner, sported ag fowner agree to the above.conditions.
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DATE
QPg'B: Waite GO); YeUcw (Tam HE); Ark (k#imit)
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