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IMAGING & MICROFILM ACCESS, INC.
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BOX 12
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01321
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PERSON INTERVIEWED PCHD Complaint #
Name & Relationship (i.e, o�aner,tenant, etc.) ��
DATE � I "i 1 �--- E FACILITY S I N
PROPOSED INSTAL1M /7 PHONE 0- - -7 S� g
Pro (include sketch locating all adjacent wells):
NOTE: Repair must be in same location and of some type as original sewage disposal system.
Different location may require submittal of proposal from licensed professional engineer or
registered architect. p
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Proposal a roved Proposal Disappr
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Proposal approved with the following conditions:
1. Procurement of any Town permit, if applicable.
2. Subzmisgion 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 conditions.
I, as owner, or reported agent of owner agree to the above conditions. q
SIGNATURE TITLE 7dVS . DATE
EMS: 4dbe (PC D); Yellow (kn HE); Pink (Applusnt)
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Bi -State Inc.
Septic Tank Service
Starr Ridge Road
BREWSTER, NY 10509
(914) 278.7565 (203) 778 -4247
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