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BOX 27
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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.
_K_;1&
�- - Proposal 'approved _
Inspector's
__. Proposal Disapproved '4
ronosal amroved with the followincr conditions:
1'. Procurement of any Town permit, if applicable.
2. Submission of as built repair sketch in duplicate showing:
a. Owner's nine.
b. Site Street Name, Town and Tax Map number.
c. Location of installed components tied to two fixed points
d. System description (e.g., 1250 gal. concrete septic tank,
drywells surrounded by one foot + gravel).
e. Installer's name and number.
Da
(e.g..,house corners).
three precast 6' diam. x 6' deep
3. System repair to be performed in accordance with the above proposal and conditions.
I, as own reported agent of owner agree to the above conditions. .
SIGNATURE
TITLE L} DATE _ I
PHS: Nike (PCHD); YeUc w (Tam HI); Pink Wpli,can)
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