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HomeMy WebLinkAbout3291DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 73. -2 -18 BOX 26 �■ 03291 'Y' ' .k` C�� #i I,` , �� ,- ��; , L1� 4 '� - eL �I m 03291 'Y' ' .k` 1 PUTNAM COUNTY HEALTH DEPARTMM DIVISION OF ENVIRONMENTAL HEALTH SERVICES 225 - 3838/225- 3833/.225 -3641 PR0 O,� - 'OR "`SEWAGE' DISPOSAL SYSTEM-REPAIR':': OWNER'S NAME �. rS y U•7 0 O PHONE SITE IDCATION rim# MAILING ADDRESS DATE #9W gyy� R Oev ova PCHD Name & Relationship (i.e, owner,tenant, etc.) TYPE FACILITY int # PROPOSED ' INSTALLER �1 vl -1 (±� �I(r� P ✓ f PHONE S �2 67/-/,f 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. 41 Proposal approved _7L� r( . `� V1 Inspector's Signature & Proposal Disapproved conditions: i'L(j ULMI=11L UL Glil_/ -LUW11 it Gi�J�Ji 1 \.ca4l�c. 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 canponents 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. A Sure�c►JU va q, W �•a / d w v;,d Ao &, t v✓�F,�.cw,x�� LUG. Da (e.g.,house corners). three precast 6' diam. x 6' deep 3. System repair to be perfomed in accordance with the above proposal and conditions. I, as owner, or reported a ent of owner agree to the above conditions. SIGNATURE - TITLE 401flk DATE S: WAte MD); Yellow 030 RC); Pink Lkliicant) '.,J WK I 41 Proposal approved _7L� r( . `� V1 Inspector's Signature & Proposal Disapproved conditions: i'L(j ULMI=11L UL Glil_/ -LUW11 it Gi�J�Ji 1 \.ca4l�c. 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 canponents 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. A Sure�c►JU va q, W �•a / d w v;,d Ao &, t v✓�F,�.cw,x�� LUG. Da (e.g.,house corners). three precast 6' diam. x 6' deep 3. System repair to be perfomed in accordance with the above proposal and conditions. I, as owner, or reported a ent of owner agree to the above conditions. SIGNATURE - TITLE 401flk DATE S: WAte MD); Yellow 030 RC); Pink Lkliicant)