HomeMy WebLinkAbout2024DOCUMENT CONVERSION SERVICES PROVIDED BY
IMAGING & MICROFILM ACCESS, INC.
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631- 589 -8100
36.40 -1 -16 & 36.40 -1 -17
BOX 18
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02024
OWNER'S NAME
SITE LOCATION
MAILING ADDRESS I/
PERSON INTERVIEWED
DATE
MOPOSED INSTALLER
AC1A
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PM Crnplaint t
Name & Relationship (.e, owner,tenant, etc.)
TYPE FACILITY
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.
'PrD ®bsc'r) Pem J2 ,-,M ',Cnsiic e�nl �•,
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, Team 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' diam. 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, o repo a t of owner agree to the above conditions.
SIGNATURE TITLE . DATE L ^
IPl & WAte MV; Yellow (fin BI); Pink (k*Uc nt)
PUTNAM COERM HEALTH DEPARTMENT it
DIVISION OF ENVIRONMENIAL HEALTH SERVICES
PROPOSAL F• • SEWAM DISPOSAL SYSTEM REPAIR
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OWNER'S NAME PHONE 9 /y- x-79 - 3 3T
SITE LOCATION SWO
MAILING ADDRESS Cie_ Ping ; Re,y / uS°, 2
PERSON INTERVIEWED ('ii✓►<l: PCHD Complaint #
Dame & Relationship (i.e, owner,tenant, etc.)
DATE /01-m- ?19� TYPE FACILITY #D A f
PROPOSED INSTALLER 3—g r"e � �1`urdy PHONE
REGISTRATION # P%C -- X31'
Pr sal (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.
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Proposal approved Proposal Disapproved
Inspector's Signature & Title Date
'roposal 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' diam. 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 reported agent of
owner agree to the above
conditions.
SIGNATURE
L,,vW
TITLE
DATE /(I p'%G
IPBS: VIAte (PAID); YeUcw M-An HI); Pink Q pUcEmt)
OWNEI
SITE
MAIL:
PERS(
DATE
.,0 0
Pro (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.
Proposal Disapproved
Inspector's S
I 4 �,
/Date
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' diam. 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, reported agent of owner agree to the above conditions.
i
SIGNATURE r` TITLE DATE
PIES: Write (PCID); YeUc w 0CM ED; Pink (Apptiamt)
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