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HomeMy WebLinkAbout4132DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 83.74 -1 -22 or 83.74 -1 -23 BOX 32 04132 ■ or 1 �l moo �r `' 1 or i6 1- . ;�• �• or r.ti In . r In 04132 PUTNAM COUN'T'Y HEALTH DEPART .. _ �J�� ="T� -� iD� .; ENVIF�ON�A�,,: FH•��?'H.. .�C�: 225 -0310 PROPOSAL FOR SEWAGE DISPOSAL SYSTEM REPAIR OWNER'S NAME c k CA ud rW I bxa,4 C R 0 Z SITE LOCATION P c, %,N-V N►ofL ,, PHONE TO MAILING ADDRESS ►► �o �.. to a r �-�. TZ n _ v x� 1 _i,�� PEA INTERVIEWED GAS 1,,0..,.� V (f_vz v'Z PCHD Complaint # Name & Relationship (i.e, owner,tenant, etc.) DATE y _ r) 4 -2 TYPE FACILITY Pro (include sketch locating all adjacent wells): NOTE: Repair must be in same location and of same type a Different location may require submittal of proposal fran original sewage disposal system. licensed professional engineer or ._.G/'� /.�"'%1�GG- •G�E�E/ �OC�c, GAD / /C.c/' G'or/c�/z��•("—c�•r 7/�.[/.� Proposal approved Inspector's Proposal Disapproved Proposal 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. i' Date r ,% c. Location of installed canponents.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, or reported agent of own agr to SIGNATURE`-�"''� /� IPgS: White MD); YeUcw ( ); Pink (kV io3nt) the above conditions. TITLE DATE