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HomeMy WebLinkAbout1968DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 36.31 -1 -37 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'