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BOX 3
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00030
OWNER'S NAIL Aikm� PHC
SITE LOCATION
1 MAM ADDRESS
/,I, 7 - ?,S-'
PERSON INTERVIEWED POO Complaint �
Name & Relationship (i.e, owner,tenant, etc.)
DATE TYPE FACILITY
PROPOSED INSTALLER � ��� PHONE
REGISTRATION #
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 engines or
registered architect.
Proposal
C.
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°s Signature & Title
W
Proposal Disapproved
Proposal approved with the following conditions:
1.': Procurement of any Town permit, if applicable.
2a' ,,Submission of as built repair sketch in duplicate showing:
�a. owner's named
;b. Site Street Name, Town and Tax Map number.
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c. Location of installed components tied to two fixed points (eog.,house corners).
d. System description (e.g.o 1250 gal. concrete septic tank, three precast 61 diamo x 60 deep
dfywells surrounded by -one foot + gravel).
e. Installer °s;aame and number.
3.; System rep�ir':to,be- performed in accordance with the above proposal. and conditions.
I, as owner, or deported agent of owner agree
SIGNATURE
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i0pM: ftte MC M; Ye] Lora MZ M BI); Fink (Applicant)
to the above conditions.
WARM
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UAlser
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