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HomeMy WebLinkAbout3095DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 62.64 -1 -26 & 62.64 -1 -27 BOX 25 loom ly% �, i� r, ,' T jq6 1 I V �I 03095 r PUTNAM COUNTY HEALTH DEPARTMENT DIVISION OF ENVIRONMENTAL HEALTH SERVICES SITE LOCATION � O OWNER'S NAME .cj. • OMC,, U221L USE ONLY �V O ,b ,y TM# jp / _1W6 q- 1 PHONE 5_2 T — 7 / V MAILING ADDRESS PERSON INTERVIEWED eyya/,/�C�r.�'� PCHD Complaint # Nark KeTationslu ., owner, tenant, etc. DATE / e / / /c PROPOSED INST. ADDRESS TYPE FACILITY G&a/� 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. s ss' Leas owner. :rPparted.agent of:; mar:a b, -tc �e cgnd tions Sta - - - - - t d or:,_ttli� £orb: 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 COPIES: White (PCHD); Yellow (Town BI); Pink (applicant) PC -RP 99ML 40 DAI(E