HomeMy WebLinkAbout4751DOCUMENT CONVERSION SERVICES PROVIDED BY
IMAGING & MICROFILM ACCESS, INC.
www.scanyourdocs.com
631- 589 -8100
91.26 -1 -37
BOX 36
04751
�
_
.�
Ir
.`
�`r
, ,
.
�
04751
PHONE
SITE IOMTION l -aKl C)e-' TO
MAILING ADDRESS 1
PERSON INTERVIEWED `7�''� -P�' PCHD Ccmplaint #
Name & Relationship (i.e, owner,tenant, etc.)
DATE TYPE FACILITY
PROPOSED INSTALLER'- PHONE
Proposal (include sketch locating all adjacent wells):
NOTE: Repair must be in same location and of same type a
Different location may require submittal of proposal from
registered architect.
607 /(- 4� Jrem
original sewage disposal system.
licensed professional engineer or
C CA-r -, v
t% D G Loses v 7-o cV ,4A4 Uu -0i v L We--ad W V &-L J
on0
P--Cl f}cA,- 6 )SfJ 7--W C 60>- -77-
Doc
- —• .� -..m. -sr. • �. . -. K. ... ... _..... ., ..� • d.. .:,�. -> -:. � < <- ,..� .r e. . �. :n.�n,: ;.q.:. �.; . _ .. --a ......., . ........w ..y. ;ti:... �..�... a,.:..:w. �..... ,..,�. �.�..: o--:. s. ', ..
Proposal approved Proposal Disapproved
-ov� 3�
Zf
�-"
Inspector's Signature CTitle
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 oorners).
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, r rted ag t of owner ee to the above conditions.
SIGNATURE TITLE DATE U c�Jd
MES: vtite (PCHD); YeUcw (fin HE); Pink (Appllcw t)