HomeMy WebLinkAbout0995DOCUMENT CONVERSION SERVICES PROVIDED BY
IMAGING & MICROFILM ACCESS, INC.
www.scanyourdocs.com
631- 589 -8100
25.46 -1 -85
BOX 10
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OWNER'S NAM
SITE IDCRTIO6
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MAILING ADMESS
PERSON INTERVIEWED Pau) Catplaint #
Name & ftlationship, (Lev owner, tenant, etc.)
DATE TYPE FACILITY
REGISTRATION #
Proposal (include sketch locating all adjacent wells) :
NOTE: iFq*r must be in same location and of same type as original sewage disposal system.
Different location may require proposal f rom � li sed professional engineer or
registered architect.
7,
Proposal approve Proposal Disapproved
Inspector's Signature & Title to
roposal 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 catponents tied to two fixed points (e.9.01house corners).
d. System description (e.g.,, 1250 gal. concrete septic tank,, three precast 61 diam. x 61 deep
drywalls surrounded by one foot + gravel).
e. Installer's now and number.
3. System repair to be performed in accordance with the above proposal and conditions.
as owner, or reported agent of owner agree to the above conditions.
SIGNATEME 0 TITLE DATE
17SM: *Ate (MM; Yellow Mai 91); Pick 092laot)
Pr-RP 97