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HomeMy WebLinkAbout1370DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 25.79 -1 -38 BOX 13 01370 r I C rl m �� � I a 01370 r1 Different location may require suhnittai oL proposal rram licensea pro=essiona.L a g-Li r.L vL registered arXitect. 19 A ??O9Egn JJ A3 . < A �cGCSi'1 N SLi C'C ?ro Poi+ ..,1 . _. r ed 's Signature & Title Proposal Disapproved 41,4)-iz 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 components tied to two fixed points (e.g.,house corners). d. System description (e.g., 1250 gal. concrete septic tank, three precast 6' diem. 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. SIGNATURE [ J Y i 1`7fil / TITLE Off% �J eL DATE 4. lqi OMS: %bite (MD); Yetlaw (fin BI); Pink (Ani im t) I; , I c; l i I �I ,I I I I _ _ -- � 7 ✓ � I I ' i1 __ ___ u° �,`�L. .� �.{ k^ yak '�,� ,., � ,� . �� < °m s i ��;� J, �, ^�'. \ `� ,.�„ ,. i _ _ _ i i ,� l ` i � 1 1 \, � �`� 1 .. I __ _.._.� _.. _.... .. _. � .._ I - � _ ... ' � � 1 I ,. _ ' Ifs �i� �" 1 I V _ — � — i l __ � ... .. �: ! 1 I- � � � � � i\ - - _.., ,� I`\ � I i -; � �/ � �1} _ _ ._ � _ � i V l � I � � I i i �' i ' ,,,_ �, �� 1, _. ., OWE SITE MAIL J DATE k%nu "zipiainL w Name & Relationship (i.e, owner,tenant, etc.) TYPE FACILITY ZCR2 aTc -Ac- PHCNE Proposal (include sketch locating all adjacent wells): NOri'E: 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 Title Proposal Disapproved A0A _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 conditions. I, as owner, or reported agent of owner agree to the conditions. SIGNATURE Gw�i� , T MATE- 020�� -�� IPI6: White (PCHD); )M lAw MyAn ffi); Pink Lk#icw t) s i �VJ e.. o_ rot ; 1 � w r T� z c J ` l Y 0 j � c SITE 'MAIL PERSON INTERVIEWED PC:FID Complaint Name & Relationship (i.e, owner,tenant, etc.) DATE TYPE FACILITY PHONE PROPOSED INSTALLER Pro (include sketch locating all adjacent wells): Nam: 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 architec . / P /.A --n cr 5;1' _b % d Proposal approved Proposal Disapproved with the following conditions: 0 1. Procurement of any avwn p@LIILLL, .LL %JVJ6.L% ALJJ.11 • 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' diem. 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. n S Al IGNATURE U ` �� TITLE DATE (5 V&te (PAD); W11CW M3n BE); Pink Qa2jj ent) CL W Z Y Oa J Z a OZ t S N d Y M LL 400 V m aaQ a Zi N O a OW ZJ ro ;7w OZJ JWLL ii.zoo Y, >O >W> W CWaK2 a / =co 0 OHy Z p ti to >. m ..p.=1 WW1 0 = OCCJcc O a� F .9'L W = U 0 1►��00 �KW q G 0 W UfNK� dpi �N C= J C 6 J C aLLLL =; i 1 Al '6/'PSCIS 8 a m N V � / Z p ti to >. m 0 = FW`2Y� dpi �N = LL o l w } W .. Z 5 Z 5 a � oIL N � N � M ti � � 0�,� day► 2 J 1\) F F- C4 ip Nom" 1p, 1O7 Z N Co O a jd N r LLCo LL Q W � Q m > Z U _0 >w Y W a v J Z J> m J y W p z W W ~ _ ~ YO > V J��N J ww' Ix z N O W °2W0 _ a�a as o � r F H Q ci (Wo ;zz r U W N