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HomeMy WebLinkAbout0545DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 zz.sa -z -z BOX 7 00545 NO �41% - -�' IN as 146 NN 'T ON I AN � , ZA , 00545 4 SITE LOCATION MAILING ADDRESS l_ /1 , 610,4154 I PHONE TO (--r Q m ap - 13 o D P rf 1-e k a = -, Iq 31 PERSON INTERVIEWED lik/0l-',�Ga r /-,�Ti -/ Y L0w,vf ) PaM complaint # Name '& Relationship (i.e, owner,tenant, etc.) DATE TYPE FACILITY PROPOSED INSTALLER 2,e �c��v�. s -a 2• -T'sv c— PHONE as S- -Z' X3 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 sulmittal of proposal from licensed professional engineer or registered architect. INMM A44 s Siq re A Title with the Proposal Disapproved o� `' conditions: L 1. Procurement of any Town permit, if applicable. TC-� �"" / 2. SuYmission of as built repair sketch in duplicate showing: -Q�✓' ' a. Owner's name. b. Site Street Name, Town and Tax Map number. c. Location of installed components tied to two fixed points d. System description (e.g., 1200 gal. concrete septic tank, drywells surrounded by one foot + gravel). e. Installer's name and number. (e.g.,house corners). three precast 6' diam..x 6' deep 3. System repair to be performed in accordance with the above proposal and conditions. [, as owner, "portedd t f owner agree to the above conditions. SIGNATURE � TITLE D DATE M: W-Lite MD); YeUcw (fin BI); Pink (Applirant) 1% E TTI Lj L Ll 4.5' Le A+ 1p 5e 4-s Lco 4- c e ot9 AP- -1-C L- Cl L,7 LZ P S,4 (All "c' e-5; c lur /2 cl 9/y. _DL.;)- , --.-"i 11' PHONE 9 SITE LOCATION <� k o /Q--d TK# MAILING ADDRESS PERSON INTERVIEWED PCHD Camplaint # Name & Relationship (i.e, owner,tenant, etc.) DATE TYPE FACILITY PROPOSED INLSTALLIIt .ms a ,- !� 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. 7 fD n r ®U e /mod. %� 1y S 1/ �% P C�C> J,�C S �lcS 7` ti Proposal approved Proposal Disapproved !� c�-- Inspector's Signature & Title Date roposal 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 canponents 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 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, or re rte C d agent of owner agree to the abovee� conditions. SIGNATURE `~ TITLE ©2c` kcL;�44�- DATE Je OPUS: V&te (PMD); )W lc w (Tam HE); Pink (Applicant)