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SITE LOCATION TO
MAILING ADDRESS - -
PEPSON INTERVIEWED PaEID Camplaint #
Name & Relationship (i.e, owner,tenant, etc.)
DATE 15. V TYPE FACILITY
PROPOSED INSTALLER ti PHONE cZ Z �I - �� d
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
Inspector's Signature &
Proposal Disapproved
Promsal awroved 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
d. System description (e.g., 1250 gal. concrete septic tank,
drywells surrounded by one foot + gravel).
e. Installer's name and number.
aac
(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- portedt of owner agree to the above conditions.
SIGNATURE TITLE DATE /
CPHS: H Ate MD); YeUc7w Mkin HE); Pink Lkliiamt)