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HomeMy WebLinkAbout1131DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 25.55 -2 -51 BOX 11 ��i, L ' '. , IN 61 1 01131 OWNEE SITE MAID] PERSON INTERVIEWED PCFID Complaint # 071-17 Name &.Relationship (i.e, owner,tenant, etc.) DATE TYPE FACILITY PROPOSED INSTALLER �O /l le,5_g / dl, Y. PHA Eli '(1nc1ude" 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. wow: w : 'PiA t S' o 2 'OeeP G"x- -� . _ 1�" 3�f� STo;ve /." Per . PUe f', i°e 8 ` Cove4 Proposal a ov /`'' Proposal Disapproved InpOedtbr !a Signature & Title Date Proposal.approved with the.-following conditions: 1; Procurement of any Town pennit, 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 cYmponents 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. SIGNATURE J,-ILA TITLE dG✓� PHS: White (MV; Ye].lraw (fin ED; Pink (Appli®nt) DATE A' t V J W I ;r G %M [TE LOCATION l% so,./ PHONE ..c2 7l 9oS5 70 PCHD Complaint # Name & Relationship (i.e, owner tenant, etc.) TYPE FACILITY 77 / /riPSo:✓ V' % PHONE 2-? i ' Y.3 S"72-" YM: Re r must be in same location and of same c (include "sketch locating all adjacent wells):. p� type as original sewage disposal-system. Lfferent location may require submittal of proposal fran licensed professional engineer, or istere3 architect. re, 1 e V) P" � S � ��l u � ' _ c� I I 1 J `VVC i�� l S'x 3 0' — 2 'OeeP o X -� T 7A i 3.�Y 5 To+ve J V\ ovC, e- ` ' /V F' perf 41 I I 1 J `VVC i�� Proposal Disapproved Inspec'tor's Signature & Title- Date :oposal approved with the following conditions: L. Procurement of any Town •permit, if applicable.. Z. 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. L System repair to be performed in accordance with the above proposal and conditions. , as owner, or reported.agent of owner agree to the above conditions. r CGNATURE / .�a' ,f� " - TITLE 01,✓164 FS: Mibe (POD); Yellow (mn HE); Pink (Appl. CEint) T 7A i J V\ ovC, e- ` ' 41 Proposal Disapproved Inspec'tor's Signature & Title- Date :oposal approved with the following conditions: L. Procurement of any Town •permit, if applicable.. Z. 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. L System repair to be performed in accordance with the above proposal and conditions. , as owner, or reported.agent of owner agree to the above conditions. r CGNATURE / .�a' ,f� " - TITLE 01,✓164 FS: Mibe (POD); Yellow (mn HE); Pink (Appl. CEint) J jr a s0 oti 1