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HomeMy WebLinkAbout0975DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 25.46 -1 -12 BOX 10 LL r e . { 00975 SITE PCHD Complaint # Name & Relationship (i.e, owner tenant, etc.) TYPE FACILITY Jo S � }� � � 'R &I A PHONE ZOS �� 42ro 7 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. ice''- ��L'l.�lS'�'�'L' ' '�.'� '. a, Proposal approved Inspector's Y0 - P � Proposal Disapproved 0 Proposal approved with the following conditions: 1. Procurement of any Town permit, if applicable. 2. Submission of as built repair sketch in duplicate showing: c a. Owners 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' diam. x 6' deep drywalls 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 TITLE DATE CAS: White (ID); Yellow (M:kn HO; Pink (Applicant)