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HomeMy WebLinkAbout0762DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 24. -1 -52 BOX 9 - m i . , -. rM L , jk6wl 00762 OWNEE SITE PHONE -1M# MAILING ADDRESS QC-ew,5Te F- ) e'w 7 o kfi�- 105,0 g PERSON INTERVIEWED 4P'fi�„�'Co A �� Wa`� �. ©Wrve� PCHD Complaint # 1"�J Name & Relationship (i.e, t, �e,+tc.) DATE �l (O I B c E?d i�1F[i �M11- R f F ACILITY c° PROPOSED IMTALT FR T : , (;fit �y "r :: PHONE AYR 1 1 P Proposal (include sketch locating all adjacent wel s):2 :18 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 arI tect. r f► l A) I P D vN F. NJ N -D (L!J C.l. q (Q. Proposal approved Proposal Disapproved Inspector's Signature & Title Date 3. Ate showing: a. Owner's name. b. Site Street Name, Town and Tax Map number. c. Location of installed canponents tied to two fixed points (e.g.,house eornersY4 d. System description (e.g., 1250 gal. concrete septic tank, three precast 6' diam. drywells surrounded by one foot + gravel). e. Installer's name and number. System repair to be performed in accordance with the above proposal and conditions. I, as owner, or reported agent of'owner agree to the above conditions. SIGNATURE 3W: T+ddte (FGD); YeUcw (Tam EI); Pink Uppliamt) TITLE DATE x 6' deep