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631- 589 -8100
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BOX 26
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MAILING ADDRESS ` >A mnC
PERSON INTERVIEWED PCHD Canplaint #
Name & Relationship (i.e, owner,tenant, etc.)
DATE TYPE FACILITY
PROPOSED INSTALLER N1 i CYO 0 R K PHONE 5d&— 17:5
Proposal (include sketch locating all adjacent wells):
NOIM: 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.
CDai-TroWti— C61 50 lr-� F je-w a, jW6-
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Proposal appr Azad Proposal Disapproved
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Proposal 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., 1250 gal. concrete septic tank, three precast 6' diam. 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 )&,_
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