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HomeMy WebLinkAbout1130DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 25.55 -2 -44 BOX 11 01130 OWNER'S NAME J SITE LOCATION MAILING ADDRESS DIVISION OF ENVIRONMENTAL HEALTH SKMCES PUTNAM COUNTY HEALTH DEPARTMENT PROPOSAL •' SEKkGE DISPOSAL REPAIR- 1 F� _!.I . / a. 1 PERSON INTERVIEWED Pa1D Canplaint # •-� Name &Relationship (i.e, owner,tenant,, etc.) DATE � °"� J ' � TYPE FACILITY PROPOSED INSTA11ER 6a?-Z-4S PHONE Z REGISTRATION # Pro (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 fran licensed professional engineer or registered architect.. -.i D K MIM - rd M I ., Proposal approved Proposal Disapproved Inspector's Signature & Title 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 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 reported apftt.,of owner agree to the above conditions. SIGNATURE TITLE 0111E 3_ ZT 00 IM: VIhite (MD); Yellnw (bn EU; Pink Ug Bast) kl o S,E: FS d I fit _ -r/j / IZZj i I q1 V7 IZZj i I