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HomeMy WebLinkAbout3998DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 83.64 -1 -37 BOX 31 Ill"ll 11 �' '• I �.� ' l IN I ` �' I em PUTNAM COUN'T'Y HEALTH DEPARTMENT DIVISION OF ENVIRONMENTAL HEALTH SERVICES PROPOSAL FOR SEWAGE DISPOSAL SYSTEM REPAIR OWNER'S NAME . . N tu'Q -S E , c 4Ai-v k o t c u PHONE SITE LOCATION J t A-s a r2 A To MAILING ADDRESS � F fc kS kJ( 9 ill PERSON IlVTERVIEWED PCB C n:plaint # Name & Relationship (i.e, owner,tenant, etc.) DATE /Z� I q -I- TYPE FACILITY Dim I4N Sliwa�;7 fL'I- to. Ltc 'V, tlS' PHONE Pro (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. _ � _oU� si J L0 v�(fN C Proposal approv Proposal Disapproved Inspector's Signature Signature & Title Date Proposal approved with the following conditions: 1. Procuremnt of any Town permit, if applicable. 2. Submisgion 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 carponents tied to two fixed points (e.g.,housse corners). d. System description (e.g., 1250 gal. concrete septic tank, three precast 6' diam. 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 or reported agent of owner agree to the above conditions. SIGNATURE :7 TITLE DATE PIES: White MV; Yellow (fin ED; Pink Lzg2 iomt)