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HomeMy WebLinkAbout0943DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 25.40 -2 -19 BOX 10 00943 111: IN, .. ' r �� - 1 L lo.. .' 1 , '' oil tiL F'�. -T ! � � ■1% , . L'�� '. 00943 OWNER'S NAME PROPOSAL FOR SEWAGE DISPOSAL SYSTEM REPAIR �a�3 -qb PHONE 2- 7� -763a SITE IDMTION ;611 t.,, &— -f,dr� tom, _ MAILING ADDRESS PERSON INTERVIEWED PAID Canplaint # Name & Relationship (i.e, owner tenant, etc.) n DATE TYPE FACILITY PROPOSED INSTALLER 621•�Z Cc' PHONE L711 REGISTRATION # Pro (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 fran licensed professional engineer or registered architect. !t/ C- A �tt�i? putcf -41 IAI Proposal approved t%n``, Proposal Disapproved Inspector's Signature & Title Dabd Proposal 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 components 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 agent of owner agree to the above conditions. SIGNATURE d z� TITLE `\ _ DATE PIS: White (Pa•D): Yellow (Ttkn HI); Pink Q pl.icBnt) PC) (o T-YLV--C? If6vo eAww I vsdr o r. n _ r.. b / rt+,4 A., Iz -97�/7( x`39 Aw A- 2--7? ! Y • 6069