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HomeMy WebLinkAbout4211DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. vA .scanyourdocs.com 631- 589 -8100 83.81 -1 -17 BOX 32 04211 .. . , IN No of OR .ti , �. 04211 p4T L, 71- _S7 9f ER OWNER' S NAME %� aim �i .� PHONE �Z 773/ SITE LOCATION lia 404(t 7- RkL 5 -S MAILING ADDRESS CAINk�� PERSON INTERVIEWED PCHD Complaint # j Name & Relationship (i.e, owner,tenant, etc.) DATE ) p ©1 q +� TYPE FACILITY PHONE 5 Z � ,Z$*' ;S" Pro (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. Proposal appr �(�" Proposal Disapproved inspecto' 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 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 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, Lr reported agent of owner agree to the above conditions. SIGNATURE � TITLE DATE la EMS: Mite (PC D) 3 YeUcw Mvin SI); Pink Lko i®nt)