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BOX 15
01615
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01615
DEC -24 -2001 11:09
P.02
PTITNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL. HEALTH SERVICES
• • / - FAI FAA
OFFICIAL USE ONLY
-®
PERSON INTERVIEWED PCHD Complaint #
Name & ReWfidnsbip Ue., owner, tenant, etc.
DATE TYPE FACILITY
• I/
Progg: ai (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 re uire submittal of proposal from licensed professional engineer or registered architect.
k, 17
Y 3 - ��
I, as o e;, or reported. g t .f owner agree to the co ditto s sta s form.
SIC CAL! TITLE OQ C /
Pm osal =roved with Jlhg followin& conditions:
I. 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 comers).
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_'
Inspector's Signature & Title
COPIES: White (PCHD); Yellow (Town BC); Pink (applicant)
PC -RP 99M L
D TE
DEC -24- 200111 :110
GO uNn'
Job. Name
Address
City
99 Maple Grange Rd., Vernon, NJ 07462 Block
I-800-420-6166 Home Phone #
Job Description
!—ryod"
Statq*-�' Zip
Lot
Date
fiblj—v 'dov A
P.03
TOTAL P.03
7'
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711
F7
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09
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7
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09
7—
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?7—
TOTAL P.03
DEC-24-2001 11:09
o
FAX
Date
Number of pages including cover sheet
Phone
Fax Phone
CC.
Fro
P.01
ALL COUNTY RESOURCE MANAGEMENT
BUILDING AND INSTALLATION DIVISION
99 MAPLE GRANGE RD
VERNON,NJ 07462
Phone 800-428-6166
Fax Phone 973-764-6404
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' . „�” •{t 5'- v -.fix n 117 v .i
b PUTNAM COUN HEALTH EPARTME
C ®�� DIVISION OF ENVIRONMENTAL HEALTH SERVICES '
P>E2 ®P ®SAI, FOR SEWAGE I)ISP ®SAIL SYS7fEM kPAIR
OFFICIAL USE ONLY
SITE LOCATION 1 - 4 TM#
o *
,,OWNERISINAI�E 4r C5 N N► ( - ' , t� ;3
MAILING ADDRESS i OAL4 r I Aty /or'/
PERSON INTERVIEWED �'YA PCHD Complaint #
ame & Relationsinp i.e., owner, tenant, etc. ,
._._DATE!
a r•• va
t :PRC)�I'OSE12IxNSTALLER (�)� [? I I �i �r -�n.1 j , �t NJ
PHONE
ADDRESS l , 1 L IIIEGISTRATION#
i i xy
E x. gT0�O :(fii6 udi sketch locatidg iH adjacent weflls)o N
4
1�0 Repair must be in same location and of same type as original sewage disposal "system .Different location �� {
'imyrrequire submittal of proposal from licensed professional engineer or registered architect.
zlg
.. .-, �:; i• i f is
i
p .
I, as Qwmer; or reported agent of owner agree to the conditions "'stated oii this form:
A£ i , (
SIGNATURE _ TITLEi� •DATE
Proposal approved with the following conditions:
1 Procurerrient of any Town permit, if applicable.
Submiss{Lon of as built repair sketch in duplicate showing
a Owner's. name - + c r _- �..
b. Site Street Name, Town and Tax Map number. ;
c.� Location of installed components tied to two fixed points (e.g.,house comers)'
d. System description (e.g., 1250 gal. Concrete septic tank, three precast 6' diam. X 6' deep "l
e. Installers' name and number. p
3. System repair to be performed in accordance with the above proposal and conditions.
Proposal approved
-� j
Inspector's Signature & Title _ DA
COPIES: White (PCHD); Yellow (Town BI); Pink (applicant) .
PC -RP 99NII,
PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
PROPOSAL FOR SEWAGE DISPOSAL SYSTEM REPAIR
OFFICIAL USE ONLY
1
SITE LOCATION 39-.13- 1-A TM# 37 ()C) 13 -�
OWNER'S NAME! J AM66 AA) MoN ► (A L[AtYn i4 PHONE $4-425 J X3.3
MAILING
PERSON INTERVIEWED mai i -LA 0tj PCHD Complaint #
—Nwne & Kelationsnip I.e., owner, tenant, etc.
DATE
TYPE FACILITY
PROPOSED INSTALLER ��W�I �5 �t�N`�T1;:�(7 i D1� PHONE 9 1J RR % ,Ro110
d f ADDRESS 31 - REGISTRATION# 7rhf
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.
-. -1 I,.as.owner,-or-.revported agent of, ownei:agree to the. conditions. stated. on.thishrrri.,____: _
SIGNATURE�%�;L%�idti- TITLE DATE J� ^ 1
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 comers).
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
Inspector's Signature & Title
COPIES: White (PCHD); Yellow (Town BI); Pink (applicant)
PC -RP 99ML
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