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BOX 11
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01037
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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,
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Proposal Disapproved
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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
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EDWAkD, JUNE RICHARDSON
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!EDWARD RICHARDSON
? 1 L JEROME DR
iPATTERSON, N.Y.
a R -44 -93
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GALLEYS
alleys (existing)
A B
29'6" 22�
Installed By: BOTTGE SEPTIC, INC
SODOM RD.
BREWSTER, N.Y.
APRIL 5, 1993