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HomeMy WebLinkAbout2963DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 62.17 -1 -66 BOX 25 02963 PUTNAM COUN'T'Y HEALTH DEPARTMENT DIVISION OF ENVIRONMENIAL HEALTH SERVICES 225 -0310 PROPOSAL FOR SF4mGE - DISPQSAI,r.SYgrr%m REPAIR v /4�7 0 OWNER'S NAME PHONE SITE LOCATION lip -� S %� S �� cYc�/ �✓ .�v %f di // �# MAILING ADDRESS PERSON INTERVIEWED Ze PCHD Complaint # Najne & Relationship (i.e, owner,tenant, etc.) / DATE 6 / a e TYPE FACILITY ✓� �° s / a/ r . � � 2 i 57 PROPOSED INSTAI,IXdt u%c/ PHONE 7 c1— ? `2 S' 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. / P .'e it (w S �/ �� 4 Q/ !� ,� �� -O �� /� 1 /� � 4 S � � e.+-, !/ ✓ "e G,J •'• t�y -,- f ,,z f'® ,,(, -0 r T - - Proposal approved_ 's Sianatur - & Proposal Disapproved 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 d. System description (e.g., 1250 gal. concrete septic tank, drywells surrounded by one foot + gravel). e. Installer's name and number. (e.g.,-house corners). three precast 6' diem. x 6' deep 3. System repair to be perfoanel in accordance with the above proposal and conditions. I, as owner, or reported agent of owner agree to the above conditions. SIGNATURE T TITLE -i1 Sv � DATE � 3PI6: Wiite (POED); YeUcw 03,n 131); Pink (Applicant) �� Pro�sal (include sketch locating all adjacent wells): NMEo 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 appr Proposal Disapproved 1�4� Inspector's Signature & Title Date Proposal approved with the following conditions: 1. Procurement of any Town permit, if applicable. 20 Submission of as built repair sketch in duplicate showing: ao Owner's name. bo Site Street Name, Town and Tax map number. co Location of installed components tied to two fixed points (eogo,house corners). de System description (e.g., 1250 gal. concrete septic tank, three precast 6' diamo x 6' deep drywells surrounded by one foot ¢ gravel). eo Installer's name and numbers 3. System repair to be performed in accordance with the above proposal and conditions. I. as owner, Zorre rte d agent of owner agree to the above conditions. SIGNATURE TITLE Guy i AP�'Ss MAte (ROE D) a YeUcw (mn EI) a Pink (kliiamt) DATE 6 —/-? — ! 7 ;i '2A1 -Al= W v-LL v j �2 6dt11 L i4G 1:5 on0 oW5 r- r t j Now :P Avv R 0 Tue fA l> %IYE—U- 5 ,7A PR0 poSL0 cep pis fio ✓ST. SCP j l [, (ff olf 1 j2 C=o fZ ;� ©If �t G O tQ O F- S 0 �2r= ✓� `2 s� r� �o a 5 76- o ��