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04607
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
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PROPOSAL FOR SEWAGE DIS7 ESCL 0 71
OZ'S NAME
SITE LOCATION
MAILING ADDRESS
PHCNE
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PERSON INTERVIEWED -V mko `-V�x_3U P� l Owm o l .) PCHD Complaint #
Name & Relationship (i.e, bwnerltenant,, etc.)
DATE E FACILITY
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 from licensed professional engineer or
registered architect.
ds
Proposal approved
Proposal Disapproved
Inspector's Signature & Title Date
Proposal approved with the following conditions:
1. Procurement of any Town permit, if applicable.
2. Submission of as built repair sketch in duplicate shaving:
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' diem. x 6' deep
drywells surrounded by one foot + gravel).
e. Installer's name and number.
3. Systgm� repair to be performed in accordance with the above proposal and conditions.
It a
Z - -- the above
SIGNkJ TITLE DATE
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