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HomeMy WebLinkAbout3861DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 83.12 -3 -46 BOX 30 . . 16.. or III O � ,'L 0';; ` r �..� . 03861 PUTNAM COUNTY HEALTH DEPARTMENT DIVISION OF ENVIRONMENTAL HEALTH SERVICES PR�I�OSA7;" 'OR SEWAGE -bjfq ',gkg REPAIR 5-2- If OWNER'S 17M 19-avA ► Cq AG L- EA, PHCNE__ SITE LOCkTIO T-CE TO . MAILING AD22 6 1, 96 ? +41. ANC-1 /051d PERSON INTERVIEWED PCHD Complaint # Name & Relationship (i.e, owner tenant, etc.) DATE 11W Lid TYPE FACILITY . PROPOSED INSTALLER Ww" Aridw.Pul PHONE _ 40 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. C41K&WAkr� JA14 �ICA- P4 44 LjC4,(,.S W . FtO o 14 5 ame. -r C Awy , , A-P - ;q'3 At- �3 3V roposal approved Proposal Disapproved Proposal awroved with the following conditions: to 1. Procurement of any Town pemit, 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 61 diam. x 61 deep drywalls 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, or reported agent of owner agree to tFleabove conditions. SIGNATUREqJLW TITLE . DATE Or 14 — _7 I JPTES: V&te (PCHD); Yellow (tn El); Ph* (An2icmit)