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HomeMy WebLinkAbout3624DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 74.11 -2 -21 BOX 29 03624 2 a- PUTNAM COUNTY HEALTH DEPARTMENT-7-:, / DIVISION OF ENVIRONMENTAL HEALTH SERVICES PROPOSAL FOR SEWAGE DISPOSAL SYSTEM REPAIR OFFICIAL USE ONLY SITE LOCATION -Lo Cn w n D 5 T M ��u wc. TM# OWNER'S NAME tM t K--- i� (- e,t r PHONE 7-F-6 MAILING ADDRESS S 4-S ,44G -c PERSON INTERVIEWED i)/ PCHD Complaint # ---Name a atlons p i.e., , tenant, etc. DATE TYPE FACILITY S S PROPOSED INSTALLER 4ZzZ,&� e �p c 7,c PHONE Z-Z- -7 yJ °J ADDRESS - �,� ✓ �o� �l ✓� REGISTRATION# ,Z Z Z 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. 1. as owner, or reported agent of owner agree to the conditions stated on this form. SIGNA / TITLE � fz° 5 DATE—\\ - " a -3 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. Proposalapproved Inspector's Signature & Title COPIES: White (PCHD); Yellow (Town BI); Pink (applicant) PC -RP 99ML DATE • e IF10 1 I ----- --- .... - - . ----------- 1 I 1 I . � . •....yam .