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HomeMy WebLinkAbout3036DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 62.18 -1 -59 BOX 25 03036 ti '16 IsF, IW]J m 03036 i :� OWNER'S NAME SITE LOCATION F�or,v 6 PUTNAM COUNTY HEALTH DEPARTMENT 4 DIVISION OF ENVIRONMENTAL HEALTH SERVICES a n PROPOSAL FOR SE1GE DISPOSAL SYSTEM REPAIR �Cd ,f17 oL P b 1•/E1� &W O rn0OU S/t e � 16 nr *cr9� PHONE i- '7 fIZ,�L4- Pa-cve TO MAILING ADDRESS loy I- ft #"� V4 L G ay i rM c • e`� 7.7 PERSON INTERVIEWED PM Complaint # Name & Relationship (i.e, owner,tenant, etc.) DATE © O TYPE FACILITY Rs PROPOSED INSTALLER JF - PHONE 57 REGISTRATION # 3 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. ROZ-177T31 0 8 Proposal Disapproved Inspector's /. ignature &' Title 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. Z�J-ZL ? 6 (e.g.,house corners). three precast 6' diam. x 6' deep 3. System repair to be performed in accordance with the above proposal and conditions. I, as owner, r reported agent of owner agree to the above conditions. SIGNATURE ✓c�/ TITLE DATE 1n/( c� P16: V&te (Pam); YeUAw (Tim ED; Pink (Appliamt)