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HomeMy WebLinkAbout4002DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 83.64 -1-44 BOX 31 �,ti ~, •� �, ' =fir :661 all •, '� , 06 r 1111 .,,, i � IN far . OWNER'S NAME _K0 r SITE IOCATION MAILING ADDRESS L. f PLTI'NAM COUNTY HEALTH DEPARTMENT DIVISION OF ENVIRONMENTAL HEALTH SERVICES 225 -0310 PROPOSAL FOR SEWAGE DISPOSAL SYSTEM REPAIR 13 `P a kc t( _ PHONE LIJ# . / PS'l f PERSON INTERVIEWED PCHD Complaint # Name & Relationship (i.e, owner,tenant, etc.) DATE 3 1 TYPE FACILITY E"(00k PROPOSED INSTALLF'.R vv PHONE 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 fran.licensed professional engineer or registered architect. Proposal approved �. Proposal Disapproved Inspector's SigratCee & Ti roposal a roved 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 cxinponents 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 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. [, as owner or reported agent of owner agree to the above conditions. ;IGNA Ur-�J- TITLE A-6 CWY T HATE .? W: White (PCHD)•, Yellow CRn ffi); Pink 0glimW