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PERSON INTERVIEW MI Pam) Complaint #
Name & Relationship (i.e, owner,tenant, etc.)
DATE TYPE FACILITY
• -� • •. DID A � yl•
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.
Proposal,approved -'L. Proposal Disapproved
Date
rcposal 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 ecmponents 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,re:ported agent of er agree to the above conditions.
SIGNATURE VZ& TITLE 5 DATE 7
3P��.S' : Hhite (PCID); 1d1Aw (fin SL); Pink Lbaliamt)