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BOX 18
■ y T ` 'T• '
f r i
OWNER'S NAME
SITE LOCATION
MAILING ADDRESS
PU NAM COUNTY HEALTH DEPART14ERP
pIVISIO(J, OF .ENVIRIONMENPAL HEALTH .SERVICES.
PROPOSAL FOR SEWAGE DISPOSAL SYSTEM REPAIR V
I
PHONE
TM#
PERSON INTERVIEWED PCHD Complaint #
Name & Relationship (i.e, owner,tenant, etc.)
DATE �S�/ ��� -,a— - TYPE FACILITY
14 ZTS)
REGISTRATION # '
/
Pro (include AdEch 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.
Proposal approved
Inspector's Signature & Title
Proposal Disapproved
ronosal aonroved with the followinq 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
d. System description (e.g., 1250 gal. concrete septic tank,
drywells surrounded by one foot + gravel).
e. Installer's name and number.
(e.g.,house corners).
three precast 6' diam. x, 6' sleep
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.
SIGNATURE - TITLE OATL•' j--
X'W: Vihite (F=); YeUcw ),. Pink (A:pli,csnt)
-T:YMMIA TIN
CORCTKS—
'-' LL EXCAVA NTAO
20 Ivy MU FA, BrewW N.Y. M 2794ft
BRIAN BARRY
8 BATAVIA ROAD
PATTERSONNY
,� ,S - t4 * t L'.
pt,�dmLake-)
5-6-02 - ..
ti
T %000 GAL. PLASTIC SMIC TANK
A T 1EL6'
B T lL6'