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HomeMy WebLinkAbout2734DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 61.08 -1 -10 BOX 23 02734 em # �� � F 'i g, t 0 ' 11L 61 � Ir r V-1 ' h UL - . 1 02734 F..- PUTNAM COUNTY HEALTH DEPARTMENT DIVISION OF ENVIRONMENTAL HEALTH SERVICES SITE LOCATION_;; Q OWNER'S NAME . J o MAILING ADDRESS OFFICIAL USE ONLY _,--/ 1-7 TM# -ID PHONE PERSON INTERVIEWED .�� �� s 1 PCHD Complaint #, Name & Relationship i.., owner, tenant, etc. TYPE FACILITY DATE PROPOSED INSTALLER '%o„�&� �Z PHONE ADDRESS 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. -51—W 2 lan' c /,� %t� �w.occ•y I. as owner; o d agent €owner agree to the conditions stated on this form. SIGNA TITLE 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 comers). d. System description (e.g., 1250 gal. Concrete septic tank, three precast 6' diam. X G 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 D TE COPIES: White (PCHD); Yellow (Town BI); Pink (applicant) PC -RP 99ML