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HomeMy WebLinkAbout1613DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 34. -5 -87 BOX 15 01613 �. . _ go .' JL I .I i . I T L �1 I . L I , ' ', I - 6 A+L-2 01613 OWNER'S NAME SITE LOCATION PUI'NAM COUNTY HEALTH DEPARTMENT DIVISION OF ENVIRONMENTAL HEALTH SERVICES PROPOSAL FOR S3-AGE DISPOSAL SYSTEM REPAIR / 0' A lee J,114 PHONE TK## c �y PERSON INTERVIEWED PCHD C Vlaint # Name & Relationship (i.e, owner,tenant, etc.) DATE TYPE FACILITY PROPOSED INSTALLER 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. /f)�,11efih e�4- &I I-AJ7Oar! -1r.hG Proposal approved Y� 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' diem. 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 repo agent of owner agree to the above conditions. SIGNATURE TITLE DATE-17/,z-,/9,,- PM: ?&be (PCED); Yellow (Tvn HE); Pink 0011amt)