HomeMy WebLinkAbout2108DOCUMENT CONVERSION SERVICES PROVIDED BY
IMAGING & MICROFILM ACCESS, INC.
www.scanyourdocs.com
631- 589 -8100
36.57 -1 -17
BOX 18
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02108
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0WM 'S NAME �Yow. ` -,owe—" PHONE '911 019
SITE LoaTION `3 1 . LUGS 1 nA L0,1kr 7 #
MAILING ADDRESS. Vic.
PERSON INTERVIEWED Cl "i ACA-1 PC HD Complaint $
Name & Relationship (i.e, owner,tenant, etc.).
DATE %" G " c(C3 TYPE FACILITY
C-1149 V Intl DI
PHONE
Pro (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 fram licensed professional engineer or
registered architect,`
'r roved Proposal Disapproved
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Ihspectorls Signature & Title Wate
'roposal 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., 1230 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 ;L- C t\, DATE `7 - 6 -- 010
C>pIFS: 6bita (PCHD): Yellow 03pn HL); Pink (AFpli®nt)
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'Bi-State. Inc.
septic Tank Service
Starr Ridee Road
BRiEWSTER,;,-,NY- 10509.. -
(914) 27$-7565 (203) 778-4247
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