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SITE LOCj
OWNER'S
MAILING
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TNAM COUNTY HEALTH DEPARTMENT .
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
PROPOSAL FOR SEWAGE DISPOSAL SYSTEM REPAIR
OFFICIAL USE ONLY
PERSON INTERVIEWED PCHD Complaint #
Name Relationship i.e., owner, tenant, etc.
DATE TYPE FACILITY aS. .
PROPOSED INSTALLER � � PHONE ,1f LtT
ADDRESS i �,,� /�c't.� REGISTRATION# AX - V << °/%
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.
I, as owner, or eported agent of owner agree to the condit' s stated on this form.
SIGNATURE'
tu4LZI 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 comers).
d. System description (e.g., 1250 gal. Concrete septic tank, three precast 6' diam. X 6' deep
e. . Installers' name and number.
3. System repair to be performed in accordance with the above proposal and conditions.
Proposal approved
Inspector's Signature & Title
COPIES: White (PCHD); Yellow (Town BI); Pink (applicant)
PC -RP 99ML
-72AIII/ou
DATE
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