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HomeMy WebLinkAbout1911DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 36.22 -1 -38 BOX 17 rm 11 sh . !x ri Ir ,I m , . i . :� 1 T I Er r 01911 a PUTNAM COUNTY HEALTH DEPARTMENT DIVISION OF ENVIRONMENTAL HEALTH SERVICES SITE LOCATION OWNER'S NAMI MAILING ADDRESS 010,rc vo"ATM# PHONE . V� OFFICIAL USE ONLY 0 — 0,3 PERSON INTERVIEWED PCHD Complaint # Name Relationship i.e., owner, tenant, etc. DATE 9_10 -0 3 TYPE FACILITY PROPOSED INNSTALLER I S�'A@TC, �f- AJ _, PHONE ADDRESS PO REGISTRATION# L01 - 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. I, as owner, or repo ed agent of owner agree to the conditions stated on this form. SIGNATURE TITLEz DATE %' !tq 101 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 WA I odo) '""' S