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OWNER'S NAME
SITE LOCATION
MAILING ADDRFS:
DIVISION OF F�IVIRONHgdJPAL AEALTH+ SERVICESi
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PROPOSAL FOR SEWAGE DISPOSAL SYSTEM REPAIR
PERSON INTERVIEWED eC- S PAID Complaint #
Name & Relationship (i.e, owner,tenant, etc.)
DATE 3 TYPE FACILITY
PROPOSED IIISTATS 0k C) LA--) PHONE 0 C)
REGISTRATION # _�`� Z
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 from licensed professional engineer or
registered architect.
C ti S -- t- U.- k"D Se r- n Pr c -r C), 't S To,-,,- -1
Z-4*� C-L-e -e- R-V -
Proposal ap�ro ,� n A Proposal Disapproved
s Sicir ature &
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 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
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 nditions.,g�
SIGNATURE i R TITLE
(rrkT n rul • Pink (Am1 iMT*)
DATE