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BOX 29
16SE ■, � ■ 610
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03790
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01,000'
DATE,. to -/ 'q
TYPE .FACILITY ... 5EOIZ06A -&6v
PROPOSED INSTALLER C, trvz FA Y PHONE,
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.pirop6sal from licensed professional engineer
.or
registered architect.
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 Nam, 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 tink,, three precast 61 diam. x.61 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 agent of owner agree to the above conditions.
SIGNATURE TITLE DATE
MES: Mite (PC FD); YeUcw Mmm EI); Pink (Appliamt) IbI x1b?
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