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DEPARTMENT OF HEALTH
TOWN OF M O N TV I LLE TAX MAP LOT PERMIT
PERMIT TO CONSTRUCT ❑ Well
❑ New Sewage Disposal System y'
Lam' Check Replacement Disposal System
Cash
Permit Fee $ o g Pay le to /e Town of m ntville •
Lot Location
Size -
lGde` i ,
Owner t_ -
Add - 'C`+c9 Tel. Nv. - - -
'-x - - ?
ress -
Contractor - License No.
Address Tel. No.
Soil Basement Facilities ( ) Baths ( )
Residence No. of Bedrooms Commercial
Water Dug Well ( ) Drilled ) Municipal ( )
j
Septic Tank - Capacity in Gal. 0--------------
( ) Garbage Grinder
Dry Wells No. -
( ) Leaching Bed
( ) Trenches
( ) Galleries
No. of Feet Depth Width
Size of Stone Size Pipe
Instructions: 1) No backfilling allowed until final inspection.
2) On space at right draw plan.
Locate 3) House Road
4) Property Lines Water Supply
5) Septic Tank - Dry wells or Leaching Tr.
6) Distribution Box
W er Su ply and leaching on adjoining property.
Signed: Date
ont etor
Approved By
Sanitarian
The private sewage system serving the above premises was constructed essentially in
accordance with plans filed with this district and the terms of the Permit issued. This
Certificate shall not be construed as permission to create or maintain any sewage nuis-
ance and in the issuance of the certificate, the Town of Montville Health Department
assumes no responsibility for the future operation and maintenance of the system.
DEPARTMENT OF HEALTH
TOWN OF M O N TV I LLE TAX MAP LOT PERMIT NU
PERMIT TO CONSTRUCT ❑ Well
❑ New Sewage Disposal System
check V Replacement Disposal System
p Cash
Permit Fee Payabl to the Town ot" M tville
sizes
Lot Location -
Tel. No. - °
Address
Contractor License No.
Address Tel. No.
Soil Basement Facilities ( ) Baths ( )
Residence No. of Bedrooms Commercial
Water Dug Well ( ) Drill Municipal ( )
Septic Tank -Capacity in Gal.
( ) Garbage Grinder
fX') Dry Wells No.
( ) Leaching Bed
( ) Trenches
( ) Galleries
No. of Feet Depth Width
Size of Stone Size Pipe
Instructions: 1) No backfilling allowed until final inspection.`
2) On space at right draw plan.
Locate 3) House Road
4) Property Lines Water Supply
5) Septic Tank - pry wells or Leaching Tr.
6) Distribution Box
Wat r u 1 and leaching on adjoining property.
Signed: - Date
ntr or
Approved B
Sanitarian
The private sewage system serving the above premises was constructed essentially in
accordance with plans filed with this district and the terms of the Permit issued. This
Certificate shall not be construed as permission to create or maintain any sewage nuis-
ance and in the issuance of the certificate, the Town of Montville Health Department
assumes no responsibility for the future operation and maintenance of the system.