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03997
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PcPrN14M COUNTY HEALTH DEPARTMENr
DIVISION OF ENVIRONM,ENrAL HEALTH SERVICES
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PROPOSAL FOR S34MO DISPOSAL SYSTEM REPAIR
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OWNER'S NAME AJV,,4-A1P 5 kLq-V14F Ag PP-MA)Y PHONE 504— "&y
SITE LOCATION Y I_ kit Lt 44® a P. CL 9 3� � & Y • l — 3 S*
,1
MAILING ADDRESS E,Cl SJ., t t O-V -A - z
PERSON INTERVIEWED PCHD Complaint #
Name & Relationship (i.e, owner,tenant, etc.)
DATE TYPE FACILITY
PROPOSED INSTALLER E PHONE
REGISTRATION # Pte- l�f �,
Pro (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 fran licensed professional engineer or
registered architect.
!Z>P
Proposal approved
Inspector's Signature &
Proposal Disapproved
roposal 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 canponents 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.
SIGNATURE TITLE Rr. olk"y— DATE
0XIES: % to MD); YeUcw (T= HL); Pink (Appl.iamt)
OWNER'S NAME AJV,,4-A1P 5 kLq-V14F Ag PP-MA)Y PHONE 504— "&y
SITE LOCATION Y I_ kit Lt 44® a P. CL 9 3� � & Y • l — 3 S*
,1
MAILING ADDRESS E,Cl SJ., t t O-V -A - z
PERSON INTERVIEWED PCHD Complaint #
Name & Relationship (i.e, owner,tenant, etc.)
DATE TYPE FACILITY
PROPOSED INSTALLER E PHONE
REGISTRATION # Pte- l�f �,
Pro (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 fran licensed professional engineer or
registered architect.
!Z>P
Proposal approved
Inspector's Signature &
Proposal Disapproved
roposal 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 canponents 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.
SIGNATURE TITLE Rr. olk"y— DATE
0XIES: % to MD); YeUcw (T= HL); Pink (Appl.iamt)