HomeMy WebLinkAbout0653DOCUMENT CONVERSION SERVICES PROVIDED BY
IMAGING & MICROFILM ACCESS, INC.
www.scanyourdocs.com
631- 589 -8100
23.09 -1 -5
BOX 8
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SITE
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Pr (include sketch locating all adjacent wells):
Na 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
revistered architect. ,
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Proposal approved Proposal Disapproved
's Signature &. Title
.th the following conditions:
Date
-I
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' diam. 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 repo ted ag t of owner agree to the above conditions.
SIGNATURE J TITLE
' " P 11: Mitre (MD); )Wlc w (pn EU s Pink (PQl..iaant)
DATE 6- b - 00