HomeMy WebLinkAbout0117DOCUMENT CONVERSION SERVICES PROVIDED BY
IMAGING & MICROFILM ACCESS, INC.
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631- 589 -8100
3.20 -1 -56
BOX 2
04- , Ll
I F rib
J6. 11L W 161
00117
OWNER'S NAME
SITE IDMTIM
�2 33 -01
MAILING ADDRESS
PUGON VIERVIIIWO) Pam) CaaFlaint #
Name & Relationship U.e, owner,tenant, etc.)
BATE TYPE FACILITY
PROPOSED IIISTALImR •SUw•Gt ,2-r e- S e d G_ c e PHONE
REGISTRATION #
Proposal (include sketch locating all adjacent wells):
.NO72: Repair must be in same location and of same type as original sewage disposal system.
Different locatiai may require submittal of proposal from licensed professi=1 engineer or
registered arciiit.:�ct.
ADD 411U,,' I aifs a In .'I y QU.Q L, ",,:, M i
Proposal Disapproved
3 y5 0
s Signature &
Proposal amroved 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' dim. x 6' deep
drywalls 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 e: agent of owner agree to the above conditions.
SIGNA W TITLE DATE �3&101
oSO& Write (PO~D); Yk0cw, (7txn HI); Pink (AVplicmit)
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