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PiTIi AM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES A2Ar- 0
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CftiEEt IS NAND roy S PHCNE
SITE LomiON r� �, S v �� -&A �-S o �# ���®Z ' � -`6 �
PAUZNG ADDRESS
PERSON INTERVIEaED C) PCHD Caaplaint #
Name & Relationship (i.e, owner,tenant, etc.) r
DATE TYPE FACILITY
PROPOSED INSTALLER PHONE ,277
REGISTRATION #
Proposal (include sketch locEiting all adjacent wells):
NOTE: Repair muss: 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 architbct.
3vor a �-- 2. x 1 �i- rr..��4�r' &Ac��.
e, f-A o
2k` I rr,,c 1... r
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 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' diem. x 6' deep
drywells surrounded by one foot + gravel).
e. Installer's name and number.
3. System repair W be performed in accordance with the, above proposal and conditions.
I, as owner, or rep�"l � of owner agree to the above conditions.
SIGNATURE / /��-' TITLE DATE -3
IPM: Uhibe MM Yellow (kn W; Pink (Appl amt)
Pr-RP 97 �