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00033
0�� PROPOSAL FOR SEWAGE DISPOSAL SYSTEK REPAIR 400�
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0S ° S Nom ' /ic to W PHONE 97?9— 695 m
SITE J=TIOAI 1?17r x
MAILING ADDRESS
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PCHD Complaint 0_
Dame & Relationship (i.e, owner,tenant, etc.)
TYPE FACILITY
PROPOSED INSTALLER PHONE ,�!7!� 4 066
REGISTRATION #
Proposal sketch locating all adjacent wells):
] M.- 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.
.f� ♦
Proposal approved
Inspector °s Signature &
with the
Proposal Disapproved
conditions:
1.1' Procurement of any Town permit, if a
2•!,Submission of as built repair sketch
a• Owner's name.
,b• Site Street Name, Town and Tax
duplicate showing:
Map number..
'tco Location of installed components tied to two
d• System description (e.g., 1250 gal. concrete
drywells surrounded by one foot + gravel)•
fined points (eogo,house corners).
septic tank, tree precast 61 diamo x 61 deep
e• Installer °s name and number.
3 .;',System repair to be performed in accordance with the above proposal and conditions.
I,.as owner, or reported a ent of owner agree to the above conditions.
SIGRATURE 7 TITLE `� �-
DATE , 1/ �
MM.-, 6diite MD); YeUcN (Tam ED; Pink Lbol.iamt)
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SITE LOCATION C �h[#
MAILING ADDRESS V3 h u :
PERSON INTERVIEWED PM Complaint #
& Relationship (i.e, owner,tenant, etc.)
DATE TYPE FACILITY
. .;• �. :M1I
PHONE 2 r) Cj � � „
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.
IM0 ,4PA
's Signature &
Proposal Disapproved
with the following conditions:
s ` L/
Bhte
la` Procurement of any Town permit, if applicable.
20' 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 61 &am. 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 repor agent of owner agree to the above conditions.
SIGNATURE TITLE DATE J-& 144
33PIM: % to (PCgD) f Yellow (Tam ED; Pink (A,ppliamt)
41 ZUMC H ROAD o R.D. D BOX 177 ,
PATTERSON, N.Y. 12563
Tony Garcia (914)279 -5206
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ro 41 ZURICH ROAD o R.D. U BOX 177
PATTERSON, N.Y. 12563
Tony Garcia
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(914)279 -5206
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