HomeMy WebLinkAbout4708DOCUMENT CONVERSION SERVICES PROVIDED BY
IMAGING & MICROFILM ACCESS, INC.
www.scanyourdocs.com
631- 589 -8100
91.25 -1 -35
BOX 35
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HCNE x'""00 S
SITE LOCATION 7t#
MAILING ADDRESS fft ` AJq
PERSON INTERVIEWED PC HD Canplaint #
Name & Relationship (i.e, owner,tenant, etc.)
DATE TYPE FACILITY
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 a rov Proposal Disapproved
A19-2 Alt, yla? 3
Inspector I s Si nature & 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' 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 repo agent of owner agree to the above conditions.
SIGNATURE TITLE DATE Y119, 3
9 T' & Wiibe GW); YeUjcw (inn HE); Pink (Anliom t)