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HomeMy WebLinkAbout3332DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 73.05 -2 -10 BOX 27 03332 U .A j , 03332 any PUTNAM COUNTY HEALTH DEPARTMENT DIVISION OF ENVIRONMENTAL HEALTH SERVICES 225 -0310 _�;;;,> ���•csA7 ^'1p C�t?_�ti�Z�'PC�'AT 'YS"i�'.i R^ATy�R. �_ _' ...,.: ', s-- - - OWNER'S NAME 19 :i.5 'n �/��� �r �n ck PHONE SITE LOCATION r°r��ner ��� 14f U� :u (�lc� .-- S`7'r�ec: 7`s SA/- 6 —a,2 .NAILING ADDRESS �{ %%%� u / 7 7`c: i' i l e- Pa '. '�h d sh f,`: -` _ L ,f% / D3 7 2 PERSON INTERVIE{aEED fit: s/ un &,e&t -t., ej ajl7 e,r- PM Ca plaint # . Namb & Relationship (i.e, owner,tenant, etc.) DATE TYPE FACILITY PROPOSED INSTALLER ,` Ci• 7 PHONE S Ak " 317 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 fran licensed professional engineer or registered architect. n ure�,J/ 1",a— 'J J 4MF `--J A �% ,� ` •44 n P— � YI hn r 5 w P- / rw I v2 2c V`'i%�$`g'yif9y/�SCr� _. .. .._ _. ... .�.�... ..,� ..__.... . sa -...s r.. _,. . .._�.,.. -., - -. �... ........a._e -. .- .a.,- .__.- e,...._ �..�.... ..... ..__ -.._._ tea^ ...... -. �..... _.�_- .. -+,4.- ..._�..�.� Proposal approved Proposal Disapproved Inspector's Signature itl ybtte roposal appraved 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 canponents tied to two fixed points (e.g. house corners). d. System description (e.g., 1250 gal. concrete septic tank, three precast 61 diem. x 6' deep drywells surrounded by one foot + gravel). e. Installer's name and number. 3. System repair to be performed in accordance with the above proposal and conditions. I, as.owner, or reported agent of owner agree to the above conditions,. ! T I � ]P1ES' : Vbibe (PQD); YeUcw ('ibhn ED; Pink Ggliant)