HomeMy WebLinkAbout3467DOCUMENT CONVERSION SERVICES PROVIDED BY
IMAGING & MICROFILM ACCESS, INC.
www.scanyourdocs.com
631- 589 -8100
73.18 -1 -36
BOX 28
03467
� ,
T
.;
,.
�
IL
%
1
9.
.
r
�
:
_
t
03467
JUN-07-2004 10:30 PM
SITE LOCH
OWNER'S I
MAILING A
PERSON IN
DATE_
PROPOSED
I
P.02
puTNAm COUNTY HFAITH DEPARTMENT
iiV -13 10);- .&mt.-,yn �- cia's
Z7
ZQJ& UNA-GIS nLVQRAL' LYAM RIUM
r o OFMLAL UN ONLY
E
Z-cy
FCHD Complaint#
TYPB FACUrY.
1r'0.gd..6 &sO' pHO1,M !F24; -A$'
0;r;fiQ3TRA110N#_.yC1
PM12all (include skitch 1oc*t1zS all adjacent Welk):
NOTE: Repair must be in same location and of same," as OdSM sewage disposal system -Differ mt location
may require submittal of pfo
posal from licensed professional engineer or regIsteLd architect.
vier -C# r
SIGNA -�
PW=Sgl "=yed with the follovdag goditional
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, Towi and Tix Map number.
C. Location of installed components tied to two fixed points (e.g.,housc comen).
d. System description (e.g., 1250 gal. Concrete septic tank, three precast 6! diem. X & deep
C. Installers' name and number.
.3. System repair to be performed in accordance with the above proposal and conditions.
Proposal appmved�
Invector's Signature & Title
COPS: Wbite-(PCHD); YOUQW (Town BI); Pink (epplkpf)
PC-RP 99ML
DATE