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HomeMy WebLinkAbout1144DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 25.56 -1 -60 BOX 11 J 1 01144 Jai - � 16 9 0 1 is 6 i E' 01144 ko, 064NER'S NAMZeo IaLTre,�z- PHONE MAIIJM ADMUM �r �1 ►� - & Relationship owner,,tenant, etc.) DAM TYPE FACILITY PROPOSED DUIALLER PHONE REGISTRATION # Proposal (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. ....: ; ' .. *,J:,* 2. 3. p s Sianature & cawua. vi GaaaX Awwaa iA. arlxiwaxc. 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 caq=ents tied to two fixed points (e.g. ,house corners) . d. System description (e.g., 1250 gal. concrete septic tank, three precast 6' dim. drywells surrounded by one foot + gravel) . e. Installer's name and number. System repair to be performed in accordance with the above proposal and conditions. I, as owner re agent of owner agree to the above conditi SIGNATURE i A" 4-� PM: Mite (MV); YeUcw (Mm BT); Pink (Aql. amt.) PC -;RP 97 x 6' deep