HomeMy WebLinkAbout0118DOCUMENT CONVERSION SERVICES PROVIDED BY
IMAGING & MICROFILM ACCESS, INC.
www.scanyourdocs.com
631- 589 -8100
3.20 -1 -62
BOX 2
1 rs
-1
v
I yti
:
LL r
I
.
r.
lk
y
,
q6
oil
Ky
Pr
00118
SITE
.1 ,0
PHONE Vg 9� 5-3 y l
2$ �ayr %sc T� �� l
MAILING ADDRESS Sra J,-�e
PERSON INTERVI PCHD Complaint #
Name & Relationship (i.e, awner,tenant, etc.)
DATE TYPE FACILITY Z,5,
PROPOSED TALLER 6? cloo, 3' PHONE _ '? // ,y — V, -5 5
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 fran licensed professional engineer or
Proposal approved ��4 Provosa proved
Inspector's Signature & 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 own4or 9r ed o owner agree to the above conditions. SIGNATUR TITLE DATE
UPIFS: W-dte (MU); Yellow (fin EI); Pink (Ppplicent)
rim
SV2VEY OF PRJC�PERT�C
P2.EPAR.inD FOR
Srr�J�TL� iN
TO�wlnl OF PA r&lzsOh1 Cj00N T ( t'1.*(
SGAL6 l" . 30� APR1L 3dL 1°/T4
LJ11AtTTHOCt•lZlsD Pu mithTLON OIL hDDLTION TO -r*s
3ue.JE'( Is A OG 6ec -rcN +iad! OF
'Ttka MEW `(DRAG STATE CDL=NrL01.► I.,A,&J,
UuoEme-mc, UD SR..L�T�RES, LF A>N Nor
AL-t- GF.2T�G�CATLCn.as vlEaEOwI ARE QW-AD Cott
r-ap T Wi6o 1w . Acc. ^¢b A mcr-- va lnl lua GM Ifm a6 TrILS NAP AI-+D COPIES T.1 && sc-G a ti-c LF
GODS OF PCA¢.C& Fpm ►. .o SURV4`(S 0,VcP-Eb SND wtgP Olt- COPIES 3CA2 IMC t$4V& SED+
IW -(FIE t4c-.4 ,,<OP-K vroam j,.�LAaTLOLJ QF SEAa- of T.16 SJRNfi`IbR Welo66 G%c,*AF%Tk>"
PROfE'SFaIONA C.I.LaD, 6t)iLJ e`CO)ZS. Apps -NRS tKREah+.
J/� j Fto 3FnT ti. �Q�' LJDO QGF
NY-S- LAC.- Ma - 0,Pf+O/
may- LJnu Pe ��.Lrr�T �Q
�� /J
M
GARAGt
�QiVEWAY
�
Aars:
• Ofd 5Cf1,'CPA
W
ro
WT U". 35 t 39 ?Eras
1B'
To LOT'S oN kimig of
Jo✓ATNA✓ A. TAe&a Fat.I0
�1
a
oA+ 56oT ", 164.0. S1MrtLi
Du PATT4nfoW TINO µAP
22
(rl'
PWA. 4 &=K 3 Lei 5.
SV2VEY OF PRJC�PERT�C
P2.EPAR.inD FOR
Srr�J�TL� iN
TO�wlnl OF PA r&lzsOh1 Cj00N T ( t'1.*(
SGAL6 l" . 30� APR1L 3dL 1°/T4
LJ11AtTTHOCt•lZlsD Pu mithTLON OIL hDDLTION TO -r*s
3ue.JE'( Is A OG 6ec -rcN +iad! OF
'Ttka MEW `(DRAG STATE CDL=NrL01.► I.,A,&J,
UuoEme-mc, UD SR..L�T�RES, LF A>N Nor
AL-t- GF.2T�G�CATLCn.as vlEaEOwI ARE QW-AD Cott
r-ap T Wi6o 1w . Acc. ^¢b A mcr-- va lnl lua GM Ifm a6 TrILS NAP AI-+D COPIES T.1 && sc-G a ti-c LF
GODS OF PCA¢.C& Fpm ►. .o SURV4`(S 0,VcP-Eb SND wtgP Olt- COPIES 3CA2 IMC t$4V& SED+
IW -(FIE t4c-.4 ,,<OP-K vroam j,.�LAaTLOLJ QF SEAa- of T.16 SJRNfi`IbR Welo66 G%c,*AF%Tk>"
PROfE'SFaIONA C.I.LaD, 6t)iLJ e`CO)ZS. Apps -NRS tKREah+.
J/� j Fto 3FnT ti. �Q�' LJDO QGF
NY-S- LAC.- Ma - 0,Pf+O/