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OWNS
SITE
MAIL
DATE
PM Complaint #
Name & Relationship ( i . e, owner, tenant, etc.) (Y► ,��-L cZ �, o r cac v+v�
//,� TYPE FACILITY
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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.
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2.
a F Proposal Disapproved
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Inspector's SignTe & Title 01.✓ to
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posal approved with the following, conditions: .ems.._,.. b
Procurement of any Tbwn permit, if applicable.
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
d. System description (e.g., 1250 gal. concrete septic tank,
drywells surrounded by one foot + gravel).
-e. Installer's name and number.
(e.g.,house corners).
three precast 6' di,am. x 6' deep
3. System repair to be performed in accordance with the above proposal and conditions.
I, aG-Owleh—, or reported agent of owner agree to the abwe conditi0qs
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4 :�1 Rules and Regulations of the
,o ty ealth Department.
PROJECT
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LAURENT ENGINEERING
ASSOCIATES, PC.'
73 FAIRFIELD DRIVE
PATTERSON, NEW YORK 12563
(914) 278.6108
CONSULTING SITE ENGINEERS
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