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BOX 31
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PLM.7M COUNTY HEALTH DEPARTMENT
DIVISION OF,
---HEALTH SERVICES
ENVIRONMENrM
225-3838/2257383302.5-3641
PHONE
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PERSON. INTERVIEWED eOMV 00 KKeLC-9jr'_ oww PCHD Cdaplainti.
-Name & Relationship U.e,'oWner tenant, etc.
DATE TYPE FACILITY
<16
PROPOSED INSTALLER. Jotw &4�tYn-T, PHONE 714 r-
Proposal (include sketch locating all adjacent wells):
NOTE :. Repair must'ID6 in. sam''.16cation and of same type.as oriiginal.*sew . age . disposal systom..
Different location may require submittal of 'p r 6posal fr an licensed professidhai 6hg :
ineer or
re#r,d:ar6hitect. . . . ,, 1..
Proposal approved
Proposal Disapproved
2.
Submission of as built repair sketch in duplicate showing:
a., Owner I s. name.
b. Site Street Name, Town and Tax Map number.,
c. Icoation 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.g.,house corners).
three precast,61 diam. x'61 deep
.e. Installer's name and number.
3. System repair to be performed in accordance with the above proposal and conditions.
I, as,ownekl, or reported agent of owner agree to the above conditions.
SIGNATURE TITLE DATE 1111,0100.
[PIPS: KAbe WD)• 1e1W (Tam HE); Pink Uqiiamt)