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HomeMy WebLinkAbout2914DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 62.15 -1 -39 BOX 24 02914 11 m or J IJim Ir 1 '■ , , �■ a: � JL m16 �. 02914 P1k1K -1 -ebb 5 by: Sy f XUM: ru i NHII WUN i i VCrHR o-,rc o- mac, PAM COUNTY TH DEPARTMENT DIVISION OF P-NVIRONMENTAL HEALTH SERVICES PROPO$AX, EQR SIRWAGE DISPOSAL SYSTEM REPAIR OFFICIAL USE ONLY lir 113-o- Ad SITE LOCATION 76; TM# 01'd • / / 3 I OWNER'S N.4IvIE 1,0 tj f _1 �! vt PHONE „ , � ' ELL Zo S � MAILING ADDRESS '1"Fro PERSON INTERVIEWED (-Q%J +er R( d o r n PCHD. Complaint # Naame & KelatIOMMP e., owner, knant, M. DATE TYPE FACILITY PROPOSED INSTALLER C ev ►, r,-rci i cd- C-,6 r, & ,,4' PHONE 011 2;(R 90/0 �cll 9i 5�D ass ADDRESS Co Ckro � )/vim h v i &A � CLAli .r� ©r REGISTRATION# PG 5-6 O p=o ja (include sketch locating all adjacent wells): NOTE: Repair must be in same location* and of same type as original sewage disposal system ,Different locatioa may require submittal of proposal from licensed professional engineer or registered architect. w fcCST �iPo�f I+er `Y-I+ m I, as owner, or reported agent of owner agree to the conditions stated on this form. DATE PLgRflcal wroyed 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 comers). d. System description (e.&, 1250 gal. Concrete septic tank, three precast &'diam. X 6' deep e. Installers' name and number. 3. System repair to be performed in accordance with the above proposal and conditions. Proposal approved Inspector's Signature & Title COPIES: White (PCID); Yellow (Town BI); Pink (applicant) PC-R? 99ML DA C - age o� o ag s: __ _ _ _rao���%ytf 3 - 7 s z - F � r II. t a MA K H- c�c 'ma' iu�T�0 D l� w F : a i '".''.'.i'r -2N �`"r,.. pw- 'x',..L'``td e°.�. s �"+'��. '"r�i �4'�` �+�1y�'O'�i' -pn� - t+�`3°' <r, jF +y,. .�. �' 'rYy �, • �, t fi: ,v�.+s.. 'e 4r3i^. tc iYas."CI F�" �"r,t✓'i k. P - �` y Y£Y+{ Owr �� i��fi' {�Y .4 J^ sz: i.',°�e� i- 2m:-�. 4 >G o P $ �� x I.. „L1C # �ilCt92#1 Q L {t�. P- 56zC�Tf13 1 r 1. f; - I �i 1. } ,€ PROPOSALSUBMITTEDTO _ *, -PHONE DATE 4 1 STREET " s _ , . , JOB YAME^ �i23 's c (( 5 .i�v q '.� �= d g L. { !rte] �j X T -i� f''^RE F ... i F .ct' q I'. ` �y �' 4..b . 4. +•.- .r._. ••' S'yn+s 5sF Q CHI' .£ >'r3 , r` °a ^. R _ _ 5 ` 6 i?= f' •N I CITY STATE =and ZIP�CODE g JOB LOCATION a ' s x x _ 11 z _ t f� . •FARCHIT6CT , _ ' , � . - -,- ^ _ .. .= _- > .- _ DATE OFPLANS ;- - r a , � _ _, -JOB PHONE a- - - . . r We hereby submit specifications and'estimatesfor ' t r } d ,,, � u�[�� .J' ¢ 9 y. J dam„ fi PS ' - . P G^ '�a Y I d S f T a f- R `5 r.- X` .. 1, 3' . §i I 11 --e-r' .S `,,;+ "'` '","s "a-r '.. 5�., r V, ,M,8 y ` 3 "3�i .`` ` y y _ f {,r y {yam}` j x .' 15 - 1. ! - ''s - - $ _ - - 2 .. t X 2` , ¢ .. _ _ •� A .,a d c s� '. i' Y X '- r+> "- • 'S3 `� . , tl 4 e� l t S "✓ v, , E.s - ;':F .S, : 1 f� y3 v� •w-, .r ,�. ,x r c r, r - ^� is a tz�..µ,5 '{�.. ;' .:." , x a w_, ' S 3> 5k $ F a q Ati ''i at { S�k•-° -'s a-s , .af -, FTh .- 'e E f �. 1 _ F - f- -� rFi i7_ - YhL•+.ss - -� t r° ' �'J- •,2 -'+ E _ z �n`X'i J'��" _' a - ;- . s, - '_> - 3. '` z 6' - 'a . _ -- - - - _ _ t .. ,_ . � Y ' y ' tee-!` l.. `1 ` - i x -, � � _ "w k " �", . , +�'�''� A ryn tea r f ''� - L s T ;'- '� ' . .b .• q .� is .� '" "tG { .63 3 tSa f ;f PV a"^7 f`.'C 'i` ll ` 'r r ka' -- 1 _ Ci{ a 4 cat ;•' 3a >6y''" Via' t � � a-"�, �'c `yf S �'. 'd` � ¢��f4 a yF=4 t r '#., t �l i I C Y y�� v C.1 Gc �._ CS3 X 2 3. i sS , 4 t r', 1 /h y s �- -. .2 --. .�': .b - - ' `1 - ,. x . ->p }Y `$ -$/ry. -' r.A '� Y' i F' `�.- "±(`({['y{ �Y- Q'(� (�.�� y n{4>� J°t3'� @+,•r �yp:{{�"/�¢( �4{''�]S.}��¢,( ��5�(+��' ��(.{ 4 i �'^ d` S Vii i Lxl''f �.1'!�v `�{ 1:4 1�3 F 4?YTiY�� C3 L LS�'��1lV��V�%xAL. 6 C:13.,�. 5 i ,, .,�„M` {UG1714�1Y - f � ' T�vi P�$YC>Oi R p -yam` ti - Fr S 3' - Y ' ; 'i�� k li}�CAt'3hG ftE [4?RFt1iON OTHER FFf .zR #itWj DISTURBED AREfiS IUDEti UNctSS'PEC � Si f EF3 PAFf0,0IIBP hereby to#furnlsh material antlM labor complete fn accordance with above speclflcatlonst for the of ;, -sum -c $ a Y a ; s'� -:_* F .x °. BY .%.` 'r 3 S 3. .sue- .1''a' 4 Y+f.. ya - dollars ($ ) ­5 Payment toy be made as follows .fµ FiII�IC TEi �i i lfPiP3,ALAP51Ea 1 '' y CF9AfiGtr CT_'PE�R 11�i7M1 f�IF}[3ED :. IL, a . GiiS1 f)MEi lam PEI F r _ _ IVSEI3l..FfRA A111Q AU CE�NES ' -. ti y ALL Qt$Pt �u II�:S 77i. fi3 TFIRt�UGF� 81141E tis-, , #ATIi�M s �: ... .. ' - - 9 J ., ' ..._ - as All smaterial is guaranteed to "be as . specrfidd 4AII' vuork to be completed n�a wo"rkmanlike •,- �" '• � " Authorized manner according to standard;practices Any dtteraf bn or deviation frdm ;above specifications' c i {involving,q;c cos "ts will be, executed onlysupon written orders and wili, become an extra Slgn3fure _e a :, „charge over and .above t of ?i sfimate� All�agrg eements, contingent upofi stokes ;accidents' s I. ,- or detaysbayond our controls Owner•to• carry iire,�tornado "arid other necessary nsurance I .-- :�4 hlS proposal may, be � �s �c 4 •� t ti r h wdhdrawn by us If not accepted withina' * - days Our workers a e fully coveredrby Workmans Compensatiori,:lnsurance , r f . , . Z. Arrrti }�t " ,Z -=_ �� 3 : : .' k ricQ miroattl The above prices specficatlons . ) 'I I, r .. .. b Sw '- S `'� -Y y,... . ... ., ... ' �" _ v"..Y°a -•A .9 fa4 •} L :.'. 5 ' L '— 3 3