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HomeMy WebLinkAbout1175DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 25.62 -1 -18 BOX 12 � , Ir Ir. � ir '5' i 0 01175 SITE PHONE MAILING ADDRESS PERSON INTERVIEWED PCHD Complaint # ' .Name & Relationshi p (i.e, owner,, tenant, etc.) DATE /� 7 TYPE FACILITY ..,§ !; •. :X �+• PHONE 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. Proposal approved Inspector's Proposal Disapproved 34 e 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 ccmponents 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. System repair to be perfonTed in accordance with the above proposal and conditions. I, as owner, or reported agent.of owner agree to the above conditions. SIGNATURE TITLE GATE CP 1;& Wiibe (MD); Yellow (fin BS); Pink (Ani iaint) ,W t Proposal approved Inspector's Proposal Disapproved 34 e 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 ccmponents 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. System repair to be perfonTed in accordance with the above proposal and conditions. I, as owner, or reported agent.of owner agree to the above conditions. SIGNATURE TITLE GATE CP 1;& Wiibe (MD); Yellow (fin BS); Pink (Ani iaint) 07/03/1997 10:25 9142795989 TYNDALL SEPTIC SYSTE PAGE 02 3 B 1.qq 2 - &4. 1'- T Sa '"MD&L SEM SVSW=. Ivy MR1 Wd c3mmyFR. WEW *fomv, 16 — — - - P -we 4..L. - - .-. - 11Q.