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HomeMy WebLinkAbout3751DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 74.19 -2 -15 BOX 29 tj I I ' JrW 03751 PUTNAM COUNTY HEALTH DEPARTMENT DIVISION OF ENVIRONMENTAL HEALTH SERVICES SITE LOCATION_J OWNER'S NAME_ MAILING ADDRES PROPOSAL FOR SEWAGE DISPOSAL SYSTEM REPAIR OFFICIAL USE ONLY rfa PERSON INTERVIEWED PCHD Complaint # —Na-ime & Relationship (i.e., owner, tenant, etc. DATE _TYPE FACILITY _PHONE � ��✓ �� ISTRATION# 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 rewiirf mbmittal of proposal. from licensed professional engineero registered architect. -,-as* o er; o r orted Z�icwner agree to the conditions -stared on'd -iis form. 2 " + SIGNA QS TITLE I�l %� DATE v 5, 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.. Proposal approved Inspector's Signature & Title ATE COPIES: White (PCHD); Yellow (Town BI); Pink (applicant) PC -RP 99NE