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BOX 28
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03509
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OWNER'S NAME
SITE LOCATION
MAILING ADDRE
PERSON INTERV
^ Name & Relationship (i.e, owner,tenant, etc.)
to
DATE L( I q(, TYPE FACILITY t Iyr-
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PROPOSED IN5 w 0L*6 C& 1— PHONE 5'?-C ^ cam? S 1
REGISTRATION #
Proposal (include sketch locating all adjacent wells):.
Nam: 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 approvA ; Proposal Disapproved
Inspector's Signature
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.
I, as owner or reported agent of owner agree to the above conditions. 4
SIGNATURE TITLE Q46 CKT DATE 2 t
?HS: .White WD); YeUcw (Zbnn ED; Pink Lbj#icent)