HomeMy WebLinkAbout1224DOCUMENT CONVERSION SERVICES PROVIDED BY
IMAGING & MICROFILM ACCESS, INC.
www.scanyourdocs.com
631- 589 -8100
25.63 -2 -30
BOX 12
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OWNER'S »
SITE Lodaim
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09-3qsL
TO 3712M,25--63 -z •-30
MULING ADDRESS
PERSON INTERVIEWED PAID Complaint #
Name & Relationship (i.e, owner,tenant, etc.)
DATE TYPE FACILITY
PMFCSED INMAUM 30,VCArr1Qr G Se MM c) 2 `3 x
REGISTRATION #
Pmposal (include sketch locating all adjacent wells):
NOS: 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.n f
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M.MMOMM'o-100 ..
's Signature &.
Proposal Disapproved
-4Z& =�
Date
%ccosal approved with the following conditions:
1. Procurement of any nm ' Tb pemit, if applies ebal .
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 c m ponents tied to two fixed points ( e.g. ,house corners) .
d. System description (e.g., 1250 gal. concrete septic tank, three precast 6' dism. x 6' deep
drywells surrounded by one foot + gravel).
e. Installer's name and number.
3. System repair to be performed in accordance withj the above proposal and conditions.
I, as owner, or reported agent of owner agre above conditions.
3IGM URE + �J/,� �`� `�-DS �'" TITLE DATE
MS: Mite (ice); YeUm Obin BI); Pink Uglkmt)
'C -RP 97
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