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HomeMy WebLinkAbout1355DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 25.78 -1 -66 BOX 13 01355 OWNER'S NAME SITE WCATI PUI'NAM COUNTY HEALTH DEPARTMENT DIVISION OF ENVIRONMENTAL HEALTH SERVICES PROPOSAL FOR SENUM DISPOSAL SYSTEM REPAIR Wit-1kie'li-i 't R goy —97 PHOm X79 - 5 5Va9 oN 6 Z elf' c 24 7 ya, a a TM# -, '79 � -66 MAILING ADDRESS //X-, c v PERSON WrMWIEWED PCHD Canplaint # Name & Relationship (i.e, owner,tenant, etc.) DATE TYPE FACILITY PROPOSED INSTALLER PHONE REGISTRATION # /11C W 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. .RII Wi r . i.�:, Pr a PP r ed Proposal Disapproved s e" Inspector's Signa & n 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 camponents 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. t SIGNATURE TITLE � 1 zTRI: Vbite (FW); YeL1Aw 6min W; Pzrk Ugilamt) Pr-pp a7 W-0 r O C,,J,- ,- 11 i C PL S C.• Srtz:�z.- Teti- -I� a�9 6'e6�