HomeMy WebLinkAbout3685DOCUMENT CONVERSION SERVICES PROVIDED BY
IMAGING & MICROFILM ACCESS, INC.
www.scanyourdocs.com
631- 589 -8100
74.17 -1 -14
BOX 29
INS- I
q4,
L i a, , T
Sol
r'
N
IS L
IN ' -' r
l
03685
19
Howard Grew
296 Oscawana Rd.
Rub-Iam Valley, NY 10579
PHCNE
SITE LOCATION SQ hILe R S r--- T A-MC �y
MAILING ADDRESS P ,�
►J -�G
ni� 41 �% X 41 L f y 04-Y . o j- 7 j
PERSON INTERVIEWED MM Camplaint #
Name & Relationship U.e, owner tenant, etc.)
DATE (Q �'( q41 TYPE FACILITY Res ,
PROPOSED iNITALL6 . 1K PCE Se-
ft J�
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.
ril�4Scci�ar �- <�,,c -d1<
Proposal appr.0
1 .
2.
3.
's
A&Tuhl
re & Title
Proposal Disapproved
wal approved with the followincr conditions:
Procurement of any Town permit, if applicable.
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
d. System description (e.g., 1250 gal. concrete septic tank,
drywells surrounded by one foot + gravel).
e. Installer's name and number.
E? I-1 �Vf
Date
(e.g.,house corners).
three precast 6' diam. x 6' deep
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.
SIGMA ��S�i ? ' �.tJ'�t`-`� • : 4. , - TITLEr 1-1-1, DATE i� � � l
PIES: White (PAID); YeUcw (Ttkin HI); Pink (ArpUa3nt)
CO/j vsvf-:�)441L,�
45
�, 0�2
/� - S ?S- 803
S-+Orf.-,V\ V.]
/f I
� -
v� 1-r i S!, v
I
1�
Q
s
C
CPO
1:2111 11
'74.
ql
42"
•y �; o pd R�DIAr
r 63
tb
fm�
IZ
IA
4k
ac 0
N17
CIL, O 1/
'4A
of 0
Ol
JO