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OWNER'S NAME i mm
SITE.` LOCATION TM# �3? ;?N0 Q 4/
MAILING ADDRESS
PERSON INTERVIEWED Pam Canplaint t
Name & Relationship (i.e, owner,tenant,letc.)
DAB TYPE FACILITY
PROPOSED INSTMJM ,,) - a .rte p v ��O e- S C'r A eta' PRONE Vt5 3 � Q -3 163
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REGISTRATION # 5-01
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 suhnittal of`proposal from licensed professional engineer or
registered architect. —J --I
s
Proposal Disapproved
r000sal avaroved with the following conditions:
1. Procurement of any Town pewit, 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
d. System description (e.g., 1250 gal. concrete septic tank,
drywells surrounded by one foot + gravel).
e. Installer's name and number.
(e.g. house corners).
three precast` 6'.' diam. x 6' deep
3. System repair to be performed in accordance with the above proposal and conditions.
I, as owner,
or rppo4ad
agent of
owner agree to the above conditions.
SIGNATURE 1,zAt
TITLE .L �k lA&C
DATE
Q S: Wite (MV; Yellow Mo In HE); Pink 042iaknt)
PC -RP 97