Loading...
HomeMy WebLinkAbout1127DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 25.55 -2 -25 BOX 11 I�yL • . I . 4 J F I L. ti f 01127 OKNE SITE PERSON INTERVIEWED PCHD Complaint # I Name & Relationship (i.e, owner,tenant, etc.) DATE TYPE FACILITY PROPOSED INSTALLER PHONE S��O owl (include sketch locating all adjacent wells): NOTE: 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. Proposal approved Proposal Disapproved &Vb�- 3 9 Inspector's Sicina ure & Title bate 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 canponents, tied to two fixed points (e.g.,house corners). d. System description (e.g., 1250 gal. concrete septic tank, three precast 6' diem. x 6' 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 owner, or reported agent of owner agree to the above conditions. r SIGNATURE TITLE DATE 7 Wf4l�r CIPW: *Ate (MD); Ye11aw (Tan BI); Pink (k#iamt) fir,,, °, ��, �� ���(�°�'o� lip -� -� I z LC lalbi -le ;,5 I 1`1 IN tv