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PERSON II VIEWID C2 W04 P� Pam) Complaint #
Name & Relationship (i.e, owner,tenant, etc.)
DATE -3 /� TYPE FACILITY
PROPOSED DET T T ',F�"p j, PHONE
REGISTRATION #
Proposal (include sketch loco ing 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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Proposal approved Proposal Disapproved
Inspector Is 'Signature & Title to
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 ccmponents 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 ported agent of owner agree to the above conditions.
SIG1=JRE TITLE DiATE -sr �'
OCPIESS: Rdte MV; YeUcw Mkn BI); Pink Vglimnt)
PC -RP 97
SUPPLY,; INC.
P.O. BOX 499.332 ADAMS ST. 9 ,BEDFORD HILLS, NY 10507
914-666-9100 FAX 914- -0992
PLUMBING • HEATING • INDUSTRIAL:* WATERWORKS