HomeMy WebLinkAbout0947DOCUMENT CONVERSION SERVICES PROVIDED BY
IMAGING & MICROFILM ACCESS, INC.
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631- 589 -8100
25.40 -2 -39
BOX 10
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00947
SITE IDWIM
PHGNET U�� D
6, 4,0 w,2 -3 R,
MAILING ADDRESS
PERSON RUERVIENED PM Qm pl,aint #
Name & Relationship (i.e, owner,tenant, etc.)
DME TYPE FACILITY
C:
PROPOSED IMTI T J ` .,PHCNE 03.2
REGISTRATION #
Proposal (include sketch locating all adjacent wells):
Nam: 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 architect.
P
Proposal approved 0'� Proposal Disapproved
Inspector's Signature & Title
roposal approved with the following conditions:
1. Procurement of any Town permit, if applicable.
2. Submission of as built repair sketch in duplicate sh6wing:
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 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, 6r r agent of owner agree to the above conditions.
i 1
SIGI�ITVRE TITLE DATE 1
OPW& Klite (MV; M91im (fin HO; Pink (Appliamnt)