HomeMy WebLinkAbout3255DOCUMENT CONVERSION SERVICES PROVIDED BY
IMAGING & MICROFILM ACCESS, INC.
www.scanyourdocs.com
631- 589 -8100
73. -1 -45
BOX 26
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.19 No
9 IL
I I J6 321
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03255
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PERSI
DATE
PROP(
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Props
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.
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Proposal apprmEied Proposal Disapproved
PIL SIY/PL-
Inspector's Signature & Title Date
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 canponents 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 reported a owner agree to the above '�condditions.
SIGNATURE- __._. TITLE ���iGG/� _. DATE /7/0 3
PINTS: V&te (PO`D): YeUc w (inn EI); Pink (Applicant)
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