HomeMy WebLinkAbout1604DOCUMENT CONVERSION SERVICES PROVIDED BY
IMAGING & MICROFILM ACCESS, INC.
www.scanyourdocs.com
631- 589 -8100
34. -5 -76
BOX 15
01604
i,yti
r'
IN
I
'
or i
,r
�rI
. IN-irmi
'-
`
'�',
'�
'16
1
.
01604
OWNEE
SITE
MAIL:
PERS(
DATE
4 6
i•
6 %11J */
DI DID Qlc� V in IF Di
TYPE FACILITY /
PHONE
Proposal (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 su)nittal of proposal fram licensed professional engineer or
registered architect.
Proposal approved _ Proposal Disapproved
r000sal aooroved with the followinq 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 canponents tied to two fixed points
d. System description (e.g., 1250 gal. concrete septic tank,
drywells surrounded by one foot + gravel).
e. Installer's name and number.
(e.g.,house corners).
three precast 6' diam. x 6' deep
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 TITLE /f�a DATE
MES: MAte (PQD); YeUcw (tnn HU; Pink (Applicant)
t
i
e
� OL
X
i;
j fl%A h
kid
r
G'kA�aC � °qd
66v
�
5 �h
N°° r
Y-
_
o Tarde - /50' ,In{-i`/) Curs - 1 �.ogo/
-1
trtN>
Jj
3
�I
II
�� Ir
r.
ffw hy. � N Nth -I , €•Ai
�U2VE`C F. P¢bPE2.T`Y . • ;:••.1�f1� +.� . .
P2eP 1R.E.O Fog '
WILLIAdA AL�\CAPIDEZ
�i17u � TE • 11.1
Tow,,t ,.bF. . Pp.T`C�.Q.Satil PUTtiIAM_•cOUt�tTY,�•`G
. SC.A.LE t "', ' So' MAPl..►� l2 � \9'7Co
JOB No. PA 71 - 1 - S
�/
CIICTI FICD Tb T'L F.+TIrAM Ga�JT`t t►wilNCt BANK
.,ND Te •M/l rTt/ 6vgeMa•T'L Go. cso, ZMG¢
Wu�-•� N0. PM 'i -o"
-M AOtlfno 'ib TIIS
C�RTIR GATeNS IND1C�Rb Ma C6AN Siam." TMAT TMIL
A - (IOLAna" OP StCTIDNd Tio"9 OP
Su aJO`I -AS PRAPAPAD Iw AeceP�DAIxL waw TMS
MG NSW (ORA VA'% QUQCATID1.1 1••A�1•
CIIS'Aldc• mtw oP ORhcrle6 PAZ LAMD SQLUO'tt NOQVMD
1
JNb&R4Q4umb 4TU=TOL19S11P AHi, IdWr Qbuw-
bt I;" PIOW -<b e,4 St'MTO AS/or A—oN eP ptnacbSn.v,[,.
AU- eBRTIRG►{T'gNt +1119600,1 M& Yt"b VbF
LAAO S.IO.ua`fot5 6-%1O SANE R.oN ONLY
'MIS ~ AMP l -,7103 THaR6oP ON.IS( IF
�b TMC Poaie" Mc wAoIA 'nc 6. 1wI X, IS PrAPARaD
MRO.&L ceP1aS 9C►•A TAti INpR&"jeD
ON MIS HGMN -F lb Tta TT4 ca"PAmv IW4 l fw1li1NC
SEAL ec T.U! SuRV9tbR WHOfg 5 414ATUQE
11JSTT VrIeu UtT6D AQG 1.101
AP P6hQS 4�6QileN.
TRANSLSRh6L4 1b n.DD1 TON/[. II�STrtUTitr.1) 02
Su BS60.161.tt' o:,y..waaRT, ` � '
qA— ' r—
Qo9Bez �. $eR'L +fJ.1poR FIC
151 K. MhW 4T.
JOB No. PA 71 - 1 - S