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HomeMy WebLinkAbout0970DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 25.41 -1 -47 BOX 10 !7L {- . L r r L, 6 h' ICY f 4�� t��� i r r i� 00970 OWNER'S NAME SITE LOCATION �►• •• •►�+• �,a�• • • � is � • • � • • ►a - ►y tip+• wa` T- MAfiitL PHam MAILING ADDREss / iqew-lcLo K4l. �5,ee, �)- sTeR- A/ jA o PERSON INTERVIEWED 44p-y Q-- i&A�nd, GNAW ep— MM Canplaint # Nanie & Relationship' (i.e, owner,tenant, etc.) f DATE 'Sf �� G� 14 F TYPE FACILITY PROPOSED IlSTATIE / 1A1eeN kh PHONE d 2L ! Z S% REGISTRATION # B 13V 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. f r nj 9AMe L o CQ �i and �K /�1E, /p RrM w e lfr.✓� , 'ePG4Ce l.� fib iv l eo / ®t© dal . G ,a ., �,��/ . �r .�Lt �i °s7Rr �'��; /`�o y Aol� &61AV-1,1. f3lozk- -pR� V-e& 0 'S� �w 9 2 -a 4A J. ` PJ,4 ,� ,` _ '.►,i /. C ' A ,.T s Sianature & Title Proposal Disapproved 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 canponents tied to two fixed points (e.g. ,house corners) . d. System description (e.g., 1250 gal. concrete septic tank, three precast 6' diam. 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. SIGMRME TITLE _ fW /ef Z. DATE 09175: Hiite (MV; YeUcw (wn HU; Pink (MF Zamt) Pr -RP Q7 s/eM YesL A wS ,14ArAc;r 'alyY�y Lt.,vF sC�tc' -fi.�NK - gox ) 3 7olye fy brNr, 6 4eys �Y CA . 1 St "►e ��e,sj v/MCemr /VW/Zp4./ -P161A LAO'�SCAFIA/, l g, nc 13y� AA-e. 7//07 i Z A �wellanG IIL .D �o -01W V 2 - /: 17 /15.1 A a6 S' yfi c' 7Aeve, 31 ' 3,�' ,3—:�O eta L. 17EY4, 37 lily . r