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HomeMy WebLinkAbout0895DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 25.38 -1 -29 BOX 10 J Wr T� �` JL 1 T` 114' ,. r6:` V �_Y w PUMM COMM HEALTH DMAMEW q �� DIVISION OF ENVIRONMENTAL HEALTH SERVICES I PROPOSAL FOR SEWAGE DISPOSAL SYSTFM REPAIR PHCNE�'7 r Z Yy PCFID CcYnplaint # Name & Relationship U.e, owner,tenant, etc.) TYPE FACILITY L PROPOSED IIZSMUF:R PHONE 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 fram licensed professional engineer or registered architect. N Proposal'= aprpvedIx Proposal Disapproved Inspector's Signature & Title to 'roposal approved with the following 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 camponents 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 drywells surrounded by one foot + gravel). e. Installer's name and number. 3. System repair to be performed in accordance with the above proposal and Conditions. I, as owner, or reported ag t of owner agree to the above conditions. �. SIGNR URE /AlK, TIME Ehe , DATE !' "M: White (FAD); YeUcw (un ED; Pink Qg1kw t) PC -RP 97 Vq -- a NO lkl-j1pru 4�r7 As,, TA%7L50,j, * 9AY flo-71--vo L� I:lj Teapo5e ,-,6 - 3, S&O GAM a:-3 40-1/&JtlL.S 1 91'1 -i� EE� -).j 66 t7i C tPUTNAK. HEALTHDEPARTHM, DIVISION OF. ENMOM,?=;.,' HEALTH: SERvicEs PROPOSAL FOR' SEDGE : "DISPOSAL ;SYSTEM REPA IR p 41 '00 'ADDRESS Relation iv-iii .Or' -rddl" UZ TYPE. `FACILITY 3GISTRATION i-Uncl &6tch - locating all adjacent two QIAF Lif entt j66jtjoh-Jmay .re ire''s' dhi I f rav icensed prof essloh ai, engineer or- ed flMd raposaliepj "—'EnspeqWrss Signature. &.Title Deft I f"• : DD %,#dth the ssion'j of as bia.lt reps 8tre''ev­"' cri pti (e V 77 (Al Ah� "—'EnspeqWrss Signature. &.Title Deft I f"• : DD %,#dth the ssion'j of as bia.lt reps 8tre''ev­"' cri pti (e V 77 (Al