HomeMy WebLinkAbout1309DOCUMENT CONVERSION SERVICES PROVIDED BY
IMAGING & MICROFILM ACCESS, INC.
www. s ca n y o u rd o cs . c o m
631- 589 -8100
25.71 -2 -18
BOX 12
llullllll�
..
SITE IDMI.
'I
PROPOSAL FOR SEWAGE DISPOSAL SYS REM. R
Ala,
PHONE -L� ' - 3 'S
oN EK ?2y i� 7 .2 5-'7/
MAILING ADDRESS el aweph" fi 1&-4 k4 reg-y _ AlY. . /0S0 Z-
PERSON INTERVIEWED PCID Complaint #
Name & Relationship U.e, owner,tenant, etc.)
DATE TYPE FACILITY AS
PROPOSED nETAiLIEt PHONE
REGISTRATION # 6V(/•
(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.
Avg
Proposal 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 components 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 performed in accordance with the above proposal and condition®`:
r '
I, as owner, or reported gent of owner agree to the above conditions.
SIGN TURE TITLE
IPIFSi Mite MM YeUm (fin Hi); Ark Unlio nt.)
i 2 '
Mr -31
10MI"i
Avg
Proposal 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 components 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 performed in accordance with the above proposal and condition®`:
r '
I, as owner, or reported gent of owner agree to the above conditions.
SIGN TURE TITLE
IPIFSi Mite MM YeUm (fin Hi); Ark Unlio nt.)
t
! `
lk-
°°61, ��
'a
°°61, ��