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PERSON INTERVIEWED 18 f_, },,i � Cor✓N y l� PCHD Cdnplaint #
Name & Relationship (i:e, owner,tenant, etc.)
DATE TYPE FACILITY' D
PROPOSED INSTALLER #t (A.-1 Q 6,J, J 0 2 CVW S PHONE G a 77
Pro posal, (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.
set
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s Signature &
Proposal Disapproved
r000sal annroved with the following conditions:
1., Procnrenent of any Town permit, if applicable.
L'Sukmi.ssion 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 components tied to two fixed points
d. System description (e.g., 1250 gal. concrete septic tank,
drywells surrounded by one foot + gravel).
e. Installer's name and number.
V/,�_ �� -
Date
(e.g.,house corners).
three precast 6' diam. x 6' deep
3. System repair to be performed in accordance with the above proposal and conditions.
I, as owre ",,r rneported agent of owner agree to the above conditions.
SIGI�7URE lGt TITLE f, , GATE
PIS: V&te MV; Ye11Aw (mn EU; Pink (AFp jan t)
.0.0. -Box 621 —
CARMEL, NEW YORK 10512
(914) 225-6277 -
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.0.0. -Box 621 —
CARMEL, NEW YORK 10512
(914) 225-6277 -
P- -7 F Sr
PEA,- GpUA-.lA,t,S'
A k t,-j C. i- � Q-
27k -a5
_4
NN
Ff\
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