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HomeMy WebLinkAbout1037DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 25.48 -1 -15 BOX 11 oil , r ` r- - 7I - -� r - I F � ` T' + 01037 cam SITE MAILING ADDRESSL_ PERSON INTERVIEWED PHONE PCHD Complaint # I A!0 fe L 4 Nwe a Relationship (i.e, owfierrfA-nantr etc.) TYPE FACUM e.s i tow e e. PHONE Proposal (include sketch lQca#ng all.adjaqent'wells): NOTE: Repair most be in same location and of same type as.0rigina 1 sewage disposal system. Different location may require submittal of proposal from lippin'P4 Professional engineer or registered aichiteqt, s I Av'r Proposal Disapproved 11 K -C.VO-- , 7 <-, - n, -,�. z A\ C, 3 Da 2. Submission of as built re pp4r sketch in duplicate showing: a. owner's name. b. site street Name, Tbwn and Tax Map number. c. Location of installed components tied to two fixed. Points (e..g' house corners). d. System, description (0.g.,, 1250 gal. concrete septic. tank, three precast 61 diam. x 61 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 ownerr, or reported agent of owner agree to the above conditions. SIGNATURE TITLE DATE ;Y ". .1 1 � � - .. J- I C �, � /9 V 3PHS: Vbibe MV; YeUcw,(T= K); Ph* (APP11cant) /is te LA- ryL a-P j, nn, J7 -ro r-c t t EDWAkD, JUNE RICHARDSON c% !EDWARD RICHARDSON ? 1 L JEROME DR iPATTERSON, N.Y. a R -44 -93 i 1 s } GALLEYS alleys (existing) A B 29'6" 22� Installed By: BOTTGE SEPTIC, INC SODOM RD. BREWSTER, N.Y. APRIL 5, 1993