HomeMy WebLinkAbout3730DOCUMENT CONVERSION SERVICES PROVIDED BY
IMAGING & MICROFILM ACCESS, INC.
www.scanyourdo,c,s.com
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74.18 -1 -115
BOX 29,
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03730
PUTNAM COUNTY HEALTH DEPAR24ENT
DIVISION OF ENVITAL HEALTH SERVICES
PROPOSAL FOR SEWAGE D SYSTEM REPAIR
OWNER'S NAME Fez %c c i PHONE
SITE IOWION 2.'f . Pogo VOS i flodg TO ght
MAILIN6 ADogEss Hi?- -A -� ix. 1 253,E ?
PERSON INTERVIEWED PCHD Complaint #
c Name i Relationship (i.e, owner,tenant, etc.)
DATE TYPE FACILITY
PROPOSED nSSTALLER Q7�,g:5 lei 6` "2i vcTczi✓ PHONE AI 2Z7-9/3 i
REGISTRATION #
Proposal (include sketch loa►ting all adjacent wells):
NOTE: Repair must be in sam? location and of same type: as original sewage disposal system.
Different location may require submittal of proposal from licensed professional engineer or
registered architect.
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Proposal approved " °� "- i Proposal Disapproved
Inspector's Signature & '.title
tpv oral approved with the fallowing conditions:
1. Procurement of any Town permit, if applicable.�� �3� •�
2. Submission of as built ie'pair sketch in duplicate showing:
a. Owner's name.
b. Site Street Name, Tbmi and Tax Map number.
c. Location of installed canponents tied to two fined points (e.g.,house corners).
d. System description (e.g., 1250 gal. concrete sg7tic tank, three precast 6' diem. x 6' deep
drywells surrounded by one foot + gravel).
e. Installer's name and dumber.
3. System repair to be performed in accordance with the above proposal and conditions.
I, as own or r en of er agree to the above conditions.
SIGNATURE TIME (!7/ -.1 91
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�':m White (PAD); Yellow (Twn HO; Pink UVPl.iaant)
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