HomeMy WebLinkAbout3953DOCUMENT CONVERSION SERVICES PROVIDED BY
IMAGING & MICROFILM ACCESS, INC.
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631- 589 -8100
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BOX 30
03953
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03953
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LA Rye. y Co b.b
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OWNER'S NAME p 1""(74 PHCNE S 2-
SITE LOCATION TO /� e
MAILING ADDRESS 4 l F-C a tf .. d 105-32
PERSON INTERVIENED Cn b CaA'1 yc r Pam Caaplaint #
Name &relationship (i.e, owner,tenant, etc.)
DATE 5-h &.h'g/ TYPE FACILITY
PROPOSED INSTALLER A w/ a R P 6e-4 c e. s --
PHONE t6' Z 6 -.l �S
PV- -r G i.-r c- 44
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 fran licensed professional engineer or
registered architect.
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Proposal appr L!
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Inspector's Sicinature &
tle
Proposal Disapproved
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Proposal apmroved with the followinct 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
d. System description (e.g., 1250 gal. concrete septic tank,
drywells surrounded by one foot + gravel).
e. Installer's name and number.
S =1- l2_
to
(e.g.,house corners).
three precast 6' diam. x 6' deep
3. System repair to be performed in accordance with the above proposal and conditions.
I, as owner, o reported agent of owner agree to the above conditions.
SIGNATURE TITLE 4C, J7, DATE d /-Fl,
PIES: V&te (MV; YeUc w (Ttkin ED; Pink (Agliamit)