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HomeMy WebLinkAbout3009DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 62.18 -1 -4 BOX 25 4 o lu L J is - f ' i'`'_, %,i, r' 3h ' r . 'I 4 o lu OWNS SITE MAII PERSON INTERVIEWED PCHD Cauplaint f Name & Relationship (,i.e, owner tenant, etc.) DATE TYPE FACILITY S % o /z\/3 PROPOSED INSTALLER CA W4?1 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 from licensed professional engineer or registered architect. �������� ✓N�� Proposal approved 2. 3. Inspector's Signature Proposal Disapproved conditions: / � r 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., 1250 gal. concrete septic tank, three precast 6' diem. drywells surrounded by one foot + gravel). e. Installer's name and number. 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. G S IGNATURE TITLE O e- ri��Fl� DATE �3 7PgS: Wite (PAD); Yellnw (T= 13I); Pink LVpli,cent) x 6' deep i - i to zr CIA V � Z �s �0075 944, Pea �N��SEO 3 (DRY 5 SPES GNM�t G (.;:,(I �A� DAA(k- i T rjlGµ� "4x.vQv -__ter :' i vj- A r OP �NL�05E0 W ri C- SL/a 13 p�-K 1! Ma-,5o,4;zy 5� // i• � ! STORE 4 5 PN LT. IZ1.13' g7�0 r' 0007. r Pik r;