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PERSON INTERVIEWED Pall) Complaint #
Name & Relationship (i.e, owner,tenant, etc.)
DATE TYPE FACILITY 1 -;0--, [� ;
PROPOSED INSTALLER) PHONE
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 fram licensed professional engineer or
registered architect.
1prov�cl �_ _ 'Proposal'
Disapproved
's Sigil,We & Title Date
'roposal 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
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 agent of owner agree to the above conditions.
SIGNATURE
PIES: White (PM); Yellow Mkn HI); Pink (Applicant)
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