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04129
OWN
SIT
MAI
PER
DATE
Name & Relationship (i.e, owner,tenant, etc.)
(� `?- TYPE FACILITY V qe- f r< V
PROPOSED INSTMIM ILI, PHONE r2-
Proposal-Unclude 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.
Proposal Disapproved
6
' 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 �aa ent of owner agree to the above conditions.
SIGNATURE ti' ' ` 'i TITLE -0� iy o k � DATE i o , r - L
IFM: V&tie MV; Yellc7w (Tan EI); Pink (. g21cm t)