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00679
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00679
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1-MMIN COUNTY HEALTH DEPAMMENT
DIVISION OF ENVIRONMERM HEALTH SERVICES
225-0310
PROPOSAL Fi ' S3Q= DISPOSAL SYSTEM RE• • 1•
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Helationstilp i.e, owner, , e
DATE I TYPE FACILITY
I i si. D1010 1k' D4i
t • i 1 LWIWUR -
Proposal (tinclude 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 fran licensed professional engineer or
registered architect.
/i5'�a /� -�ir'- GaE?'�,��5. �i5 ,fii.��../ %f l��o�l� �'Ja � �•�
Proposal approved Proposal Disapproved
Inspector's Signature & e
Proposal approved with the followinc: 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 cxmponents tied to two fixed points (e.g.,house corners).
d. System description (e.g., 1250 gal. concrete septic tank, three precast 6' diem. x 6' deep
drywalls surrounded by one foot + gravel).
e. Installer's name and number.
3. System repair to be perfonued in accordance with the above proposal and conditions.
I, as owner, or ramrted ag of owner agree to the above conditions.
SIGN NTM TITLE /L - DATE
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QP�S: Wtlibe (FAD); ffi); Pink (Askant)