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HomeMy WebLinkAbout3081DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 62.63 -1 -37 BOX 25 x1flool oil a No soll WIM91 91 ,- E� .: I IN , O , ; , �r NN rt , .- .� x1flool OWNEI SITE MAIL: PERSON INTERVIEWED PCHD Complaint # Name &Relationship (i.e, owner, tenant, etc.) DATE TYPE FACILITY PROPOSED INSTAUM 61-2 PHONE ✓�•�� 7/ 7� 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 approved Inspector's Signature & Proposal Disapproved cate 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' diam. x 6' deep drywells 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 report agent of to the above conditions. SIGNATURE TITLE O DATE MIS: WAte (FAD); Yd1cw (Tan HE); Pink (A AUCEink)