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HomeMy WebLinkAbout2794DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 62. -2 -14 BOX 24 h y, _ 6m T Ll ' JLL ` 02794 %3;''l l i,�--y's PUTNAM COUNTY HEALTH DEPARTMENT DIVISION OF HEALTH SERVICES 225 -0310 PROPOSAL FOR SEWAGE DISPOSAL SYSTEM REPAIR �-.� ;;7 .. .� v....yl&, S.!...... -r •.. , OWNER'S NMZ R 13 , 1M U o a PHA 572- 7 5-.r S- SITE Ia:ATION l�.A z° %l SA// -7'01 � Q TO 6 ► 3 MAILING .ADDRESS . E a 7 !7c < Ic s 14,' 11 14-c i 1© c& A E? Lk a-1A 0, Y , / PERSON INTERVIEWED C)� uk -t N- PCHD Complaint # Name ,& Relationship (i.e, owner,tenant, etc.) DATE TYPE FACILITY I PROPOSED INSTALLER 7 PHONE 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. & / �[ ` 4iy -!/r ^' "-- 'y -,'P/o Proposal apprcvQdA�Z7±_ Proposal Disapproved Inspector's Signature & Title DWe Proposal approved with the following conditions: 1. Prc carement of any Town permit, if applicable. 2. Sukxission of as built repair sketch in duplicate showing: a. Qaner I s name. b. late Street Name, Town and Tax Map number. c. location of installed components tied to two fixed points (e.g.,house corners). d. ;stem description (e.g., 1250 gal. concrete septic tank, three precast 61 diem. x 6' deep aTwells surrounded by one foot + gravel). e. Installer 's name and number. 1 3. Symtnn repair to be performed in accordance with the above proposal and conditions. 1 , as c Aer, or "reported agent of owner agree to the above conditions. US: vibe MD); Yellow (inn 8I); Pink (kgliamt) i TITLE DATE _ -5- 7 9 a f, e lit p`L to it 0 617 gi, f 3 °: cc) — ir^ rf Al F< A c Cpl-9 �� 31 F q7 -3� 's? .47,5- 70 CIA ill Al F< A c Cpl-9 �� 31 F q7 -3� 's? .47,5- 70