HomeMy WebLinkAbout4696DOCUMENT CONVERSION SERVICES PROVIDED BY
IMAGING & MICROFILM ACCESS, INC.
www.scanyourdocs.com
631- 589 -8100
91.25 -1 -7
BOX 35
CIO
OWNER'S NAME
SITE IACATION
MAILING ADDRESS a Jk
PHONE
TO
PERSON INTERVIEWED PCHD Complaint
Name & Relationship (i.e, owner,tenant, etc.)
DATE I TYPE FACILITY
PROPOSED INSTALLER - nG PHONE �� .�` 41 S9 Its 40
Proposal (include sketch locating all adjacent wells):
NOM: 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..
to It co a,
E
' s Sicrnature &
Proposal Disapproved
1o;
to
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 canponents tied to two fixed points (e.g.,house corners).
d. System description (e.g., 1250 gal. concrete septic tank, three precast 6' diam. x 61*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 U ILA,- Q
GATE
PgS: White (PAD); YeLLow (Tom ffi); Pink (A�plimnt)
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TK OAldl-1U j
4 % ,, ( Page No. of Pages
JACK'S. CONSTR.UCTION O.F. MPHEGAN, INC.
3635 Hill Blvd Suite 522
JEFFERSON VALLEY, NEtN YQRK 1Q535
PROPOSAL TO ..
SEh.
PHONNpE( \ ` '
DATE
/SUBM(ITTED
1
STREET
JOB NAME
CITY STATE AND ZIP CODE _
ke
JOB LOCATION
°-
ARCH ITECT,':,.` I
a
DATE. OF PLANS
J08 PHONE
_ We hereby submit sp reifications and estimates for. ` )
y.'
+ ���•`' ,G / I�-, . �. . /�"�c.'� �' /G �fs',� r j �`r��'� `f';7'`f_ +� /"`•nom ,�
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hlP1�D}tII6P hereby to furnish material and labor — complete in accordance with above specifications, for the sum .of:'
dollars
Paymerit to be made as follows:
All material Is guaranteed to be as specified. All work to be completed in a workmanlike
manner accord ngltostandard practices. Any alteration or deviation from above specifica• Authorized5�""
- `>:pons involving extra costs'Iwillfbe executed ;only upon written orders, and will become an Signature •'°+`'f i
extra charge over and above the estimate. All agreements contingent upon strikes, accidents T
or delays beyond, our control. Owner to carry-fire, tornado and other necessary insurance. Note: This proposal may be
Our workers are fully covered by Workmen's Compensation Insurance. withdrawn by us if not accepted within `; v. 1 #days.
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�rrr rWrf of FrAP0,001 -The above prices, specifications Ll
, •= and,conditi6hs are satisfactory and are hereby accepted. You are authorised Signature
`46 do the work as specified. Payment will be,made as outlined above.
f Signature
of
,r Y;Date ,Acceptance: —� —r
PRODUCT I IRd lrr_ Won. Mm 01471. To dOe PHONE TO11 FREE I+ SDO-225-SM