HomeMy WebLinkAbout4367DOCUMENT CONVERSION SERVICES PROVIDED BY
IMAGING & MICROFILM ACCESS, INC.
www.scanyourdocs.com
631- 589 -8100
84. -2 -18
BOX 33
,��n
T
I�yL
III
K'tv ;Lim
IF
LEI
IN
ti
r-
I
IL
1
N
r. ,
,��n
i')
OHM
SITE
MAIL]
PERS(
DATE
PROPC
Pro (include sketch locating all adjacent wells):
NOTE: Repair must be in same location and of same type as original sewage disposal system.
Different loca464 may require submittal of proposal fran licensed professional engineer or
registered arct4te6t.
r N /{ ;o f CIS &L,1, F 0
.`J1 C�_f.filt�v�., -' - week Cr�ircr/r�eC}
t..z
Ok-
Proposal Disapproved
Date
,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-fepo" ag of._owaer - agree,to the above conditions.
SIGNATURE '�i `;l i Z� - -� TITLE a!�1E2 DATE O
l
3QW: ftbe MD); YeUcw Mvn HE); Pzrk (Aaiiamt)
y a v C,7 t'-
f 7AC /t-- 0 #19 C-1515
F.
i
r
G141, s
/® P ilc-- 5tff/Z T/TN X�
-01-0
live
am
2-5 pot
D-� I., <�f &t/ ..
rP
,415
r
• C7 .
/000 P
014 r1ftI)c f-Il't -ro I iy
:j
,,6� 5-: 71 11^4
d
l
. i
h�
Y
9,9
r, A& - o r JAW5�
.RV,
�i
AL