HomeMy WebLinkAbout4028DOCUMENT CONVERSION SERVICES PROVIDED BY
IMAGING & MICROFILM ACCESS, INC.
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BOX 31
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SITE
DATE
PCEID Canplaint #
& Relationship (i.e, owner,tenant, etc.)
L- TYPE FACILITY
PROPOSED INSTALLER 2,r e r G ! P c 'Y G PHONE � S So-), / a
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.
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Proposal approved _ Proposal Disapproved
is
roposal 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 mama, Town and Tax Map number.
c. Location of installed camponents tied to two fixed points (e.g.,house corners).
d. System description (e.g., 1250 gal. concrete septic tank, three precast 6' diem. x 6' creep
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, o re ezi t f owner agree to the above conditions.
SIGNATURE TITLE DATE
=S: Ttbite (PAD); Y-- low HL); Pink (Anl.icent)
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