HomeMy WebLinkAbout1086DOCUMENT CONVERSION SERVICES PROVIDED BY
IMAGING & MICROFILM ACCESS, INC.
www.scanyourdocs.com
631- 589 -8100
25.54 -2 -7
BOX 11
1 1:.
PHONE
SITE I=TION ZGi Fc? • 1-0 -111 e )00 q, G' "V -Y TO Q /tc* fn4M L4 k Q..
MAILING ADDRESS S?" e --5 4
PERSON INTERVIEWED PCHD Canplaint #
Name & Relationship (i.e, owner,tenant, etc.)
DATE TYPE FACILITY
PROPOSED INSTALLER %,P r' 9' q I Y1- Q PHONE 21r °'.T a.0
Proposal (include sketch locating all adjacent wells):
MOTE: Repair must be in same location and of same type as original sewage disposal system.
Different location may require suksnittal of proposal from licensed professional engineer or
registered arch'tect.
�h o� l� /7 a w g e pq C-en 4k. oi r0 a.5 ale v o s,
Proposal approved
/G
Inspector's Signature
Proposal Disapproved
roposal approved with the following conditionsi.
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 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
drywells surrounded by one foot + gravel).
e. Installer's name and number.
3. Systen,repair to be performed in accordance with the above proposal and conditions.
�y as owner, or reported agent of owner gree to the above conditions.
GNATi]RE v` , TITLE
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