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HomeMy WebLinkAbout3818DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 83.12 -2 -21 BOX 30 ' Vo Pik A'.!j ' i �I IL Ir 6 J ,� R PUTNAM MINTY HEALTH DEPARDU NP DIVISION OF ENVIRAL HEALTH SERVICES 225 -0310 PROPOSAL FOR_SFMGE DISPOSAL SYSTEM _REPAIR ... _,;.mss .... -. _ . ..... _ OWNER'S NAME 1 J M A.:'d + J A-u C -f (S� R % Pp o PHONE SITE IMTION e co u Pip � N� M 4'� -I /,e� .N MAILING ADDRESS , t M -e PERSON INTERVIEWED PCHD Complaint # Name & Relationship U.e, owner,tenant, etc.) DATE TYPE FACILITY PROPOSED INSTALLER kit 4 k PHONE 6'- 4­9 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. K-,e- Ptf)-c-p- - r_ x i s-- i tic b f,, Ci-e // S iA,, S "r•4 e. t o 7-, e A "W -�, �, G<&--z. o,, u- A-./ v Ca�j-c, 7`6 Proposal approved, Proposal Disapproved — 'MOM roposal 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 corners). d. System description (e.g., 1250 gal. concrete septic tank, three precast 6' diem. x 6' deep drywells surrounded by one foot + gravel). e. Installer's name and number. 3. 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 ©GyA/ -c/Z DATE ' S — Z d —a q PM mite MD); YeUlcw (Tom HO; Pink (kj2icent) ,� 'r. {d 'i !C 1 �, � Q y9� e± i - - l ;. M Cc lv_ h j} Q All toy its, 7 4 �(' ATA s- ¢ 4 g F; QVI _ �(� v of `- _ - �� = t f } jQ L� sty i) �i 4(' 0� Gy 3 3 _ i r _ rte.` :- x•` _ � i ...Y i 1 z i) �i 4(' 0�