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HomeMy WebLinkAbout2798DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 62. -2 -21 BOX 24 No *NMI '� .�y M T IN L IN J r �� .■ � T ' I 1 4 1 1 I :■ ' L T- IN I� IN ON WIN 0 IL 02798 PUTNAM COUNTY HEALTH DEPARTMENT DIVISION OF ENVIRONMENTAL HEALTH SERVICES PROPOSAL FOR SEWAGE liISPOSAL SYSTEM-REPAIR OFFICIAL USE ONLY SITE LOCATION 62 OWNER'S NAME v MAILING ADDRESS_L PERSON INTERVIEWED_ DATE �- / PROPOSED INSTALLED ADDRESS �?0 4✓ y ul TM# PHONE PCHD Complaint # TYPE FACILITY PHONE 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. /4-5 ;11� l c I., as owner, _ .reported aAnt of owner agree to the conditions stated r� this fcr-n. SIGNATURE 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 6' 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 A COPIES: White (PCHD); Yellow (Town BI); P' , applicant) PC -RP 99ML flu-,