HomeMy WebLinkAbout0830DOCUMENT CONVERSION SERVICES PROVIDED BY
IMAGING & MICROFILM ACCESS, INC.
www.scanyourdocs.com
631- 589 -8100
24.07 -1 -19
BOX 9
1
11
1
1
I
I
�
,
1.
-
�
.16
11: 1
SITE LOCATION'
OWNER'S NAME
MAILING ADDRESS
PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
V
MA 0-DUZA
OFFICIAL USE ONLY
y/7 0
TM#
PHONE Z /
PERSON INTERVIEWED PCHD Complaint #
Name & Relationship (i.e., owner, tenant, etc.
DATE
PROPOSED INST.
ADDRESS
TYPE FACILITY 0'' �S i C1(c�nG,a
PHONE[y
'RATION# e? 3
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.
I, as owner, oor reported agent of owner agree to the conditions stated on this foim. -
SIGNATURE G: �/L ^'" TITLE DATE L
Proposal approved with / followingrconditions:
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
e. Installers' name and number.
3. System repair to be performed in accordance with the above proposal and conditions.
Proposalapproved�
Inspector's Signature & Title
COPIES: White (PCHD); Yellow (Town BI); Pink (applicant)
PC -RP 99ML
ATE