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HomeMy WebLinkAbout1378DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 25.79 -1 -67 BOX 13 01378 IN 6 or rl6 VJ6 �: . .1 ! 1� I r-164. III : 01378 PUTNAM COUNTY HEALTH DEPARTMENT DIVISION OF ENVIRONMENTAL HEALTH SERVICES PROPOSAL FOR SEWAGE DISPOSAL SYSTEM REPAIR OFFICIAL USE ONLY SITE LOCATION P n TM# OWNER'S NAME Q4a Pr ` PHONE g2l- MAILING ADDRESS PERSON INTERVIEWED PCHD Complaint # Name & Relationship i.e., owner, tenant, etc. DATE TYPE FACILITY PROPOSED INSTALLER, rtd��r perr `>�,,(% ,, A1, ��� PHONE_ 3 -.y,6 . ADDRESS -?L/ Oi iZL A-,:� Ak' REGISTRATION #� 6"-' 0 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 liceAsed professional engineer or registered architect. I,. as owner,' po a ent of owner agree to the conditions stated on this form.. - SIGNA TITLE( �,g DATE C� 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 e. Installers' name and number. 3. System repair to be performed in accordance with the above proposal and conditions. Proposal approved_ L ."� a Inspector's Signature & Title DATE COPIES: White (PCHD); Yellow (Town BI); Pink (applicant) PC -RP 99NE