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BOX 32
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SITE
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PERSON INTERVIEWED PCBD Caaplaint #
Name & Relationship (i.e, owner,tenant, etc.)
DATE 612'j l 7. TYPE FACILITY
PROPOSED INSTALLER 'T' PHONE
REGISTRATION _#
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 proposal fron licensed professional engineer or
registered architect.
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Proposal approved �-- 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 camponents tied to two fixed points (e.g.,house corners).
d. System description (e.g., 1250 gal. concrete septic tank, three precast 6' diem. x 6' deep
drywalls 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.
SIGNAZURE 7. TITLE t lam-'( DATE z
OOPgS: V&te (FAD); YeUc w (fin ED; Pink (Applicant)
Pr-PP 07