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01958
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01958
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PERSON INTERVIEWED
DATE
PROPOSED INSTALLER
PCHD Complaint #
Name & Relationship (i.e, owner,tenant, etc.)
TYPE FACILITY
PHONE 7 g- G o 6 �
Prsal (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 arc hiWt. - �--
Proposal approved
's
Proposal Disapproved
Da
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 camponents 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 ,CAR TITLE -� L1AM iJ � z ° �y
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JOHN MARTIN
MAP 149J
LOTS C3049-50-51
30 BATAVIA
PATTERSON, N.Y.
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JOHN MARTIN
26 BATAVIA RD.
PATTERSON, N Y
MAY 10, 1994
R-88-94
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Tank 19, 61
Box 1 411 25'
Bottge Septic, Inc.
Sodom Rd.
Bkewster, N Y