HomeMy WebLinkAbout35.-5-28 (2)DOCUMENT CONVERSION SERVICES PROVIDED BY
IMAGING & MICROFILM ACCESS, INC.
www.scanyourdoes.com
631- 589 -8100
35. -5 -28
BOX 16
!i- 3 a --00t-
PUnIAM COUNW HEALTH DEPAR'IlMEW
DIVISION OF ENVIRONMEMAL HEALTH SERVICES
SITE UXATION
PHONE rhA Z)..0 - F)�,, 7
mil# Q � 75 -03
MAILING ADDRESS / S y R ,l 2 2_ Vsa r 7
PERSON PCHD Ca:galaint #
& Relationship (i.e, owner,tenant, etc.) %�
DATE TYPE FACILITY
PROPOSED IIZSTALLIIt .Q o �. r _��� ✓r �r,.� n rn PHO M Gf,0 6 2$ -O 9.S �
REGISTRATION #
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 suhnittal of proposal from licensed professional engineer or
registered architect.
/Z SST &LL-
co Ar 7�j
TIOW/C /r(/
s f�i�r PL�9c
W s Az �
2 0
a � ' r —a5� ,9) 5
1,41 /=
i.
2.
3.
7-0 r9AJI uJ Ce- L s o 7A C-A
5S 50
approved V
I,./1.. � �A__�P
s
with the
Proposal Disapproved
conditions:
Procurement of any Town permit, if applicable.
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.
Date
(e.g.,house corners).
three precast 6' diem. x 6' deep
System repair to be performed in accordance with the above proposal and conditions.
I, as owner, hgr /Yeported agent of owner agree to the above conditions.
OFM *dbe'(M3D) j eUnw \illkn BE); rink U ZZ"."' t)
PC -RP 97
' - � � d � �'•�••• fix.,
rq X
E X51,
117 0y creo9> x 1
Ak-
lit
pa
AA15
I R f5 P-04V tr /Z -roh C. 5
Al" 6/u A) I C-,(- L d 43
Sir ors c Tow'K
no
F
I.