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Inspedt ., Signature '&,: Titl - " , - ,,, ." " , .. , - .. , . - - .. ,.,,,.,, . �. Inspector's s I . & -, .. . __ . . ... . - ., . - - . �'!� 1. . ­�.. . , "..­. .L. . , , , - , * - *.-*.:* %. ''.. - :", , to . - ., :. I - - , * I ... . -� - . .­... . , . . _ . L � - :.� � , " q . .. . I .. .", � ... - "'.... , �A . ..�.��'. . ... . " I. I , , , 1.. . ,:..a . !.: .., .. I . . ". , - . 'the 'following 'condit,ions:**�:,:.*.:' ,. Proposal �.. � .. , . .. I. .­&. ` , with . , . � ­ . I . . ll�!_applicable.: :. .1, lo -, Procdrement:of::wy,.--.ToWn' , if. - , , . :.: . �-.: "permit,.: _. . . . � . . . I I . %� . ... . . . . . .... I . . L. . . . .. .. ... i ' ' I . ". I'll ., & ...'t , '-_ .., .1 . .. . I . '.. .S�l " , - .,. t . r duplicate built I" - ssion.:of �,as­b"Uil ' e�.airske��h in. . showing: . . � *. ' .. 11 . .., ....: .� I .., '­ ". . - I I � . . - .. .7 L.... " • qwpeOU .:� rM o­:,�­' , ".. , � � � . .. - :�..::�..,_ ' , �q ' i' " number: , :�:::,:.&I . 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Vel . ... ... . 1. ....�L1,4k"... I . . . g;a. , .. .:. . _1 . ... , , . ; _� I : I'' ... . ... . , ,.!,­:I . " - . . ..& I �: - I - ". .j. . I �.. � '. I ..... . . , - .1 ,� . . �::..-, _ s tz U 6 k ! s', n: * aimi' ei,.-. and � ' � I I . , , , '#c.�-.Im number. - -.' - . . . . .. �;, � *:` �:,� i .... '' -i­­ ..­ ... ­::.... . , , �: * ,.,... ".�. - -;,�:. , ":, .Q . ......." ,,, "'. . � . 1. . . ...n �. . . .­ � ...-:;� .,�, , . _ ­ . . :,;�:,. , ,�... ... , �� I ­ I ... 1. ....'... , ...... . ,. -, -;... , . .-b., ... ;- I . .. .­ .... . '. . I "'..­.- . _.,k� ­111 .�': 1, �_. : . ,� , I :.',4:��tl. conditions. 3.," - *repair�%to��._ - - - r' 66 :-,'4h. accordance with the proposal ,. and 1... MS. , - . � ��pe . . , � ''.., � I .. . - - - IF.7' R!%�� _ . . � . I ; . .. ,".... , Z..` I _."', 1%M�`,, , ­.e.,4.1" -�:-_`�"t'.":��'�: %:"' `­­ l.v- , : .1 ,,j��4 _<.4�;o: %;.l..", .., ;-,.,'�"..-�t;'-,-��.,'-'.�:;�:�,7,..".,,:"- ._*rV..* ." .,&, .. -:� � , � .. 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HEALTH DEPARDOU DIVISION OF HEALTH SERVICES PROPOSAL FOR SEWAGE DISPOSAL SYSTEM REPAIR • SITE LOCATION /C% ' -;51 /�1T�tsic�aJ' ; g /'/. 21# FILING ADDRESS PEiiSON INTERVIEWED PCB Complaint # Name &Relationship (i.e, owner, tenant, etc.) DATE TYPE FACILITY PROPOSED INSTALIM ` - OA& :i PHONE 7757- l oQ:. 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 engineer or registered architect. . 0I • c.Z' _SCI RM Proposal approved Proposal Disapproved Inspector's Signature & Title i . 2. 3. Mal approved with the following conditions: Procurement of any Town permit, if applica ebl . 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. (e.g.,house corners). three precast 6' diem. x 6' deep System repair to be performed in accordance with the above proposal and conditions. I, as owner, qr..reported agent of owner agree to the above conditions. SIGNATURE TITLE DATE f 12 TPgS: Rd be (POM Yellow (fin SL); Pink (P plic w t) PC -RP 97 4 -A Z-0 C - a, i, l 1 _ 2 � q- %' Aa, ,,, . Iii � z f t `tiV I Fill i t