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HomeMy WebLinkAbout3817DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 83.12 -2 -15 BOX 30 03817 ru ri J ; ti �. 03817 P PUTNAM COUNTY HEALTH DEPARTMENT DIVISION OF ENVIRONMENTAL HEALTH SERVICES OFFICIAL USE ONLY (DATE TE LOCATION % 1 'Tf-� 1 TM #j f !� WNER'S NAME i PHONE it y } a Y e+ -05-r AILING ADDRESS RSON INTERVIEWED PCHD Complaint # ame Relationship (i.e., owner, tenant, etc. © TYPE FACILITY i�.S PROPOSED INSTALLER j f� m PHONE ✓ 2-61 ADDRESS REGISTRATION# Pe- 13� Proposal (include sketch locating all adjacent wells): T� 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. I57-1 MA tooe, r.i, e-', CorV-CXi9-:,r4 T6fH4. owner, o reported _ ent of owner agrde to the conditions stated on this form:. _, SIGNA TITLE AA �9iW -r Proposal approved with the following conditions: 1. Procurement of any Town permit, if applicable. 2. Submission of as built repair sketch in duplicate showing: DATE G 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 corners). 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. 3,:� Inspector's Signature & Title DATE COPIES: White (PC) ID); Yellow (Town BI); Pink (applicant) PC -RP 99ML RCT viW 7-d `' /A 6leiq (oc - ,P-W 0 -f , I Rd porn L/4 lvt, ✓ JVJ�, / 4PROF L P'OR SMWE DISPO ►il, �STII�i RE°`P.�%R; ..... ':v., � .. > , \d®8L7J: I S NAME L, 9.6 VI le 9/44✓ ( Shcy. E SITE IMTION C� U 2 , p 1 � it / To f 15- - P� FAILING ADDRESS Fy 1` 1 ki 8- W V 4 L1--%. U,! 7 � ® 5- 2 F PERSON INTERVIEWED PC€ D Canplairit 0 Dame & Relationship (i.e, owner,temant, etc.) DATE `� 3 TYPE FACILITY �� S PROPOSED INSTALLER � PHONE S- REGISTRATION # 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 fr6a licensed professional engineer or registered architect. A I 0 (L a K i -4 e _ V-P44 r V-& .4,kA- - wit 6 4(,,e ��g /'r94� I I S'f}yh,� f�nC /�- rWjsl• �� C��C,Fi/� 7D ���5't /.<''` (y��r I Proposal apV6. /,. Proposal Disapproved 's Signature & Z Date 'roposal approved with the following_ conditions: 1. Procurement of any Town permit, if applicable. 20 Submission of as built repair sketch in duplicate showing: as Owner's name. ba Site Street Name, Town and Tax lap number. co Location of installed components tied to two fixed points (eogo,house corners). do System description (e.g., 1250 gal. concrete septic tank, three precast 6' diaame x 6' deap drywells surrounded by one foot + gravel). eo Installer's name and number. 3e System repair to be performed in accordance with the above proposal and conditions. I, as owner, r reported agent of owner agree to the above conditions. SIGNATURE TITLE J MTE aMS: Vhite (FAD); YeUcw (Tarn BE); Pink (k#1=0 qT to Cv WOO n- 13T-TI L fl� 3 - 3 3 c 2Ec� VN r 14C -r4NA - _ 7°