HomeMy WebLinkAbout2010DOCUMENT CONVERSION SERVICES PROVIDED BY
IMAGING & MICROFILM ACCESS, INC.
www.scanyourdocs.com
631- 589 -8100
36.39 -1 -51 6 & 10
BOX 18
...
so
.,h , '
rk
,D
oi
J -ir
f - L
Sl ,
IN
ANo = �j',
02010
OwNE1
SITE
MAILING ADDRESS
R
PHONE C.V
TO .5 = z- 2, P
11,dzX 9� 3i , u 35ff-
PERSON INTERVIEWED PAID Canplaint I
Name & Relationship (i..e, owner,tenant, etc.)
DATE -- -- TYPE FACILITY:
..,• ' C:i DI DID oil, 49 V 0 is D4 '
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 submittal of proposal from licensed professional engineer or
registered architect.
Proposal Disapproved'
hill
(Date
Proposal approved with the following conditions:
1. Procurement of any Town permit, if applicable.
a 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' diem. x 6' deep
drywalls 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 p DATE
0
2�'t�5: Hhite (POND); YeUc w (Tam HE); Pink Qq2 icmit)
t
�
. .
t
New
�Z- C
7HN�f
3
�
- o
�f� o S-- 19A
: o
r
It
e
H
a
O
V
0
x
X79
Ird4 ��� ��� �h` k-
reP .2— ya `
0
L ,T TPFi lj' Sco GHQ
..
t3 -`
0
v
,
o
�
ri
A
�J
l vP G�'k�
G9' GG'
'A F
cz
�F
� J
V I �
► 0 ��� SAL
ti� Tangy
1 -v x