HomeMy WebLinkAbout2035DOCUMENT CONVERSION SERVICES PROVIDED BY
IMAGING & MICROFILM ACCESS, INC.
www.scanyourdocs.com
631- 589 -8100
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BOX 18
02035
0*=, s NAME S'G�TT l✓,
SITE LOCATION J�8 y A�
I' •• aa' �,al' 1 *
PERSON INTERVIEWED Pam CCmplaint #
Name & Relationship (i.e, owner,tenant, etc.)
HATE TYPE FACILITY
PROPOSED IDSTATIM _�� PHQNE 0299,- CM-
REGISTRATION #
Proposal (include sketch locating all adjacent wells):
Nam: 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.
- &, i I I I _ . _ ...
s Signature &
rocosal aoaroved with the following conditions:
1. Procurement of any.Vown 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
d. System description (e.g., 1250 gal. concrete septic tank,
drywells surrounded by one foot + gravel).
e. Installer's name and number.
0
MV% I - .
(e.g.,house corners).
three precast 6' diam. x 6' deep
3. System repair to be performed in accordance with the above proposal and conditions.
I, as owner, or r rted agent of owner agree to the above conditions.
SIGNATURE �U G TITLE DAM TITLE
IP1F5: V&te (M); Yellow (7tvin Ell); Pink ftplicmit.)
PC -RP 97