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ONS-T-RUCTIO.N_APPROVAL,
HAS PLAN REVIEW FEE.DEEN PAID? YES NO
PLAN APPROVAL: DATE APP. BY
DESIGNER: �'_11 7_119-415 PLAN DATE. / 4
CONDITIONS
FORM U APPROVAL: APPROVAL i•U IS:iUL' YES NU
DATE ISSUED BY
CONDITIONS:C�i�i��/�',U�
FINAL APPROVAL:
ALL PERMITS PAID YES NO
WELL CONSTRUCTION APPROVAL YES NU
SEPTIC SYSTEM CONSTRUCTION APPROVAL YES NO
OTHER YES NU
ANY VARIANCE NEEDED YES NO
FINAL BOARD OF HEALTH APPROVAL: DATE: BY:
WATER SUPPLY:
TOWN
WELL
WELL PERMIT
DRILLER
WELL TESTS:
CHEMICAL
DATE APPROVED
TERIA
I
DATE (IPPRUVED
BACTER
II
DATE APPROVED
COMMENTS:
FORM U APPROVAL: APPROVAL i•U IS:iUL' YES NU
DATE ISSUED BY
CONDITIONS:C�i�i��/�',U�
FINAL APPROVAL:
ALL PERMITS PAID YES NO
WELL CONSTRUCTION APPROVAL YES NU
SEPTIC SYSTEM CONSTRUCTION APPROVAL YES NO
OTHER YES NU
ANY VARIANCE NEEDED YES NO
FINAL BOARD OF HEALTH APPROVAL: DATE: BY: