HomeMy WebLinkAbout1292DOCUMENT CONVERSION SERVICES PROVIDED BY
IMAGING & MICROFILM ACCESS, INC.
www.scanyourdocs.com
631- 589 -8100
25.71 -1 -36
BOX 12
01292
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OWNER'S NAME
SITE LOCATION
PUTNAM COUNTY HEALTH DEPARTMM -37
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
L - - e ej �e PHONE
MAILING ADDRESS ' 4)ea 44 P x-s o ,v 7V—,—V • /a S
PERSON INTERVIEWED POM Canplaint #
Name & Relationship (i..e, owner,tenant, etc.)
DATE TYPE FACILITY
PROPOSED INSTALLER e S Lq-k So an PHONE
REGISTRATION #
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.
Proposal approv -
lnspector-s
Proposal Disapproved
with the following conditions:
L 17
Date
1. Procurement of any Town permit, if applicable.
2. Su)mission 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 reported agent of owner agree to the above conditions.
SIGNATURE
LFg.& V&te (PM); Yellow ('an EU; Pink (,Applicant)
TITLE DATE
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