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HomeMy WebLinkAbout2024DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 36.40 -1 -16 & 36.40 -1 -17 BOX 18 Ltiti IL ,I . �QI T4r T- T ` 02024 OWNER'S NAME SITE LOCATION MAILING ADDRESS I/ PERSON INTERVIEWED DATE MOPOSED INSTALLER AC1A Zka�� mm 2-7i- 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 r / 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. ak`ll G- arl�rL 1►�/ 12� � A�. over O d rc o 7�cr � •. �ltvoo� -,1 Tnh. ��d� ��' sv :�r�_ r�s�,afi � -T` �3 � �'�t?ce� ki-lb- -n is TA C'�:iVC l G// Q,W„ d d1/ is gAL g�.Ive vll VZ-f • Q/to s 4g,,40! T ca r Fly! � : i1 le, 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) �dLiv O �dLiv