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HomeMy WebLinkAbout1384DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 25.79 -1 -87 BOX 13 01384 r I r ' r 66� N- ok is ' 1� amp J6111 01384 of- SITE LOCATION S� ( 9s �, PHONE c2 7 9- 7 ?r Z Q l* 71I# MAILING ADDRESS 3g Q P hR-.. P (R'r'rEJe_% 1 f I'l 3 PERSON INTERVIEWED Vi o tit AM g.L% CC q1,J l�l V PCHD Complaint Name & Relationship U.e, owner,tenant, etc.) DATE A0 L. V cd q - VqQ t TYPE FACILITY PUjj RTF i4 OMh PROPOSED INSTALLER 1rJ !_U W 1;F]2 ,b LE PHONE Pro osa.l (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. /s)CPbS EA )+A ��1 ' J�� i"�= lJ RY W &I'L &)x 75 t�1il o / . _A 1�t „ . _ .. ;LA I low W-44 WAR �i� / ` tip • �� � rCAAVW=A c� E a' 77/j��, OAY f 80 1_7 .US M 01F' t �" 6 " :)ved Proposal Disapproved 's SiVature & Title —' CU41rk Procurement of any Town permit, if applicable. C Submission of as built repair sketch in duplicate showing:: to a. owner's name. L16-11— 11 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. Date I, as owner, or reported ag t o owner agree to the., above: conditions.__ -_: SIGNATURE L� TITLE 0— DATE d U11 1S: Rdte (PAD); Yalcw (fin ffi); Pink UW i®nt)