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00956
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00956
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••••. •• `1� hH 4 D V18'DI• 1.
OWNER'S NAME 11&41, O PHONE
SITE IACATION J D 20
MAILING ADDRESS
PERSON INTERVIEWED, +_. PCHD Complaint #
Name & Relationship (i.e, owner,tenant, etc.) n n
DATE --1�6 TYPE FACILITYrcicX�..`#,'o��
PROPOSED INSTAI.L"R _'S'Ct�T �i r _ PHONE - -`Z�6
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 from licensed professional engineer or
registered architect.
4.-06A ��
Proposal approved PC_ ` Proposal Disapproved
Inspector'
& Title
Proposal approved with the followinq 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
d. System description (e.g., 1250 gal. concrete septic tank,
drywells surrounded by one foot + gravel).
e Installer's name and number
a i
(e.g.,house corners).
three precast-6' diam. x 6' deep
3. System repair to be performed in accordance with the above proposal and conditions.
I, as owner, or repo agent agree to the above conditions. //.
SIGNATURE TITLE r�.qj DATE 6-15 -' 6.
FHS: Hhibe (PAD); Ye11cw (fin ED; Pink Lkiii ant)
BIA
47A2Ff-V;r..,
PO Box 992
Brewster -NY 10509
Sunday, September 29, 1996
AS BUILT -- 0150v'
Woomm
10 &1antner, 1%
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mlain drain