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03210
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03210
DATE TYPE FACILITY
PROPOSED INSTALLER f-2) v (, 1:12 R
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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Proposal appro Proposal Disapproved
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& Title
Inspector's
'Date
Proposal approved with the following conditions:
1. Procurement of any Town permit, if applicable.
2. 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' 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.
[, as owner, or-reported ent of er agree to the above conditions.
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