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BOX 32
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04153
OMMI S NAME R° p, ,4-. M4 J L y is ( ? 1 c O c c- ri ( PHONE Z g `^ % 9 Y 7
SITE LOCATION % 1z S "f L A-ff Cig'"/tz 1 710 F3 2 o�
MAILING ADDRESS
PERSON INTERVIEWED Pam Complaint #
_ Name & Relationship (i..e, owner,tenant, etc.)
DATE 2 S TYPE FACILITY o� 't--4 It Re-s
PROPOSED INSTALLER I.v- -6 r� /�-T " 0- Co 6e c PHONE . !` Z JG
0- 1.3 fi�
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 from licensed professional engineer or
registered architect.
Proposal Disapproved
Awl
Inspector's Signature & Title
J
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 ent of owner agree to the above conditions.
SIGNATURE TITLE DATE
PUS: Vihite (MD); YeUcw (Mm ED; Pink (A i i®nt)