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HomeMy WebLinkAbout0108DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631 - 589 -8100 3.20 -1 -17 BOX 2 %. rl V1,; IN Ir 16 FIJ. . . ,`]IN �J rL 1 �. ,, ■ �, ■ I� I , I I , L _ ■- N , IN IN 111111 6 11111 1 SITE MAILING ADDRESS PHONE 9 / d/ — 3 TO 3-2.6 .,1 / 7 PERSON INTERVIEW MI Pam) Complaint # Name & Relationship (i.e, owner,tenant, etc.) DATE TYPE FACILITY • -� • •. DID A � yl• PHONE ` Proposal (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,approved -'L. Proposal Disapproved Date rcposal 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 ecmponents tied to two fixed points (e.g.,house corners). d. System description (e.g., 1250 gal. concrete septic tank, three precast 6' diam. 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,re:ported agent of er agree to the above conditions. SIGNATURE VZ& TITLE 5 DATE 7 3P��.S' : Hhite (PCID); 1d1Aw (fin SL); Pink Lbaliamt)