HomeMy WebLinkAbout1942DOCUMENT CONVERSION SERVICES PROVIDED BY
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BOX 18
01942
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mm's NAME ( --' . T L d k 1m S PHONE
SITE LOCATION /-/-q ie-�e r R tzeam l a k.0 TO
MAILING ADDRESS He, d le,✓ N APm a t, _ L. , l 2-., '% 3
PERSON INTERVIEWED PCHD Canplaint #
Name & Relationship (i.e,'owner,tenant, etc.)
DATE TYPE FACILITY
• •,• • •. III � � �' r c - ... - .
T•ml. Z,
REGISTRATION # .
offal (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 fran licensed professional engineer or
registered architect.
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Proposal ..p . _. 10'� Proposal Disapproved
a
s Sianature & Title
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 canponents 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 DATE
PnG: Vbite (PAD); YeLlaw (fin HI); Pink (AFpUcmit)