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HomeMy WebLinkAbout1924DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 36.23 -1 -18 BOX 17 ., ra •, - 'I Ir 16 r so A 11 i 01924 ON Sr MA PERSON INTERVIEWED PCHD Camplaint # Name & Relationship (i.e, owner,tenant, etc.) DATE Q TYPE FACILITY PROPOSED ItiTAUM PHA 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 submittal of proposal from licensed professional engineer or registered architect. , n Proposal approved __Zf�j Proposal Disapproved Inspector's Signatufe & Tffl - e Date Iroposal 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 above conditions. SIGNATURE ��- TITLE PIES: White (PAD); YeUcw (Tam ED; Pink (APPUaRnt) I i�1r - IIIIII:,I�:�,(V BOB BRILL Owner, R. F. BRILL EXCAVATING Land Clearing • Drainage • New Septic & Repairs Drive Ways New & Repaired • Large & Small Deliveries of Sadd Stode- &° Gravel ©-Snow - R,0moval - -& -More Visa & Mastercard Accepted • Over 15 Years Experience RD 2 Box 506, Pawling, NY 12564 (914) 8555610 7. 4 A A H ro A r -- v - •Q To K n L/ 11 - 110 G - f3 ��� -