HomeMy WebLinkAbout4268DOCUMENT CONVERSION SERVICES PROVIDED BY
IMAGING & MICROFILM ACCESS, INC.
www.scanyourdocs.com
631- 589 -8100
83.82 -2 -41
BOX 32
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OWNER' S NAME 4,4 tJ r i 0-1 -T 9 PHONE
SITE I=TION ZI Z To /0 6,•/ 3
MAILING ADDRESS to, go'x 3 a 9 /�� --t J o z, z N V /y r3 2
PERSON INTERVIEWED 2 w,u err PCHD Complaint #
Nam & Relationship (i.e, owner,tenant, etc.)
DATE T e TYPE FACILITY �/�10.7
PROPOSE[) INSTALLER. ,4 ; r y PHONE go
Proposal (include sketch lgcating 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
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'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 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' diem. 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 agent of owner agree to the above conditions.
SIGNATURE TITLE
PIES: NAbe (P HD); Yellow (Tan HI); Pink ftplicm t)
nAma
Telephone 1914) 528 -6842
Cleaning Specialist of
DIGESTERS
IMHOFF TANKS
SEPTIC TANKS
CATCH BASINS
BOOSTER PITS
OIL PITS
OIL STORAGE TANKS
INDUSTRIAL SLUDGES
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Lake Drive ® Lake Peekskill, WY. 10537_
EASTERN STATES SEPTIC CO. .-TRENCHING
DAINAGE $EDS
ANY TOWN OR STATE SEPTIC TANKS
CESS POOLS INSTALLED
K. R. UM A SONS CITY DIS. PLANTS
Raymond K. Lietz i Kenneth J. Lists SWIMMING POOLS FILLED'
Owner & O-aerator :.
Telephone (914) 528 -6842 lake Drive a Lake Peekskill, N.Y. 10537
5 .5
Cleaning Specialist of EASTERN STATES SEPTIC CO. TRENCHING
DIGESTERS DRAINAGE BEDS
IMHOFF TANKS ANY TOWN OR STATE SEPTIC TANKS
SEPTIC TANKS CESS POOLS INSTALLED
CATCH BASINS K. R. LIM a SONS CITY DIS. PLANTS ,
BOOSTER PITS SWIMMING POOLS FILLED a�
Raymond K. lief: i Kenneth J. Vets I'
OIL PITS Owner i Operator !;
OIL STORAGE' TANKS
INDUSTRIAL SLUDGES
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