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HomeMy WebLinkAbout4251DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 83.81 -2 -55 BOX 32 04251 NN L me elm ' IN .' r �6 081 I IN �. 1 �, , 04251 I PUI'NAM OOtJN'I'Y HEALTH DEPARTi►OTP V DIVISION OF ENVIRONMENTAL HEALTH SERVICE'S ..... ..: . -'Y .__ "__• "'.. Ga. �. :, ::,: v ....�:.;:.: ry�_; � -:. 'c L,. :- - - -.. . -T --.,. ..5- :� �.t==�' �: ... -P -� -- :--- ___= :SdT -, ::: -;;� .�. g�_ :..+p - PROPOSAL FOR SEWAGE DISPOSAL SYSTEM REPAIR 3 OWNER' S NAME L IL( SITE I=TION c C/1- 5"T K 4Z x 3,;z 1 PHONE ?�- Z � —A YVI To 03,S- I - 2- 5 � MAILING ADORES$ I� �� � i f eiK ('I r ,LW , � � 19 % PERSON INTERVIEWED POD Complaint # Name & Relationship (i.e, owner,tenant, etc.) DATE oL ILI 3 �rL TYPE FACILITY PROPOSED INSTALLER y t,�AX-0 &A 664-f PHONE REGISTRATION # 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. C LJ Suet 'VC `7 4- L. tST r K. 0 - e /L (..,4C A Alu1 . p� � -� 0 e tf e-& o%c 6 - `-,-' s-,_ )c Cy r( /V C Li) e-. [ clr - _ -•^fe �RU ".G:3 -...= a.v :.-. e-. ��- v•- _- .4_...- r-- ..._.._.���R -.. �.+_- ..- -.- -T- _ _..�..w -. �o �.b♦ - .iwv -�Cy ai.m..: a.0 .—. r_-. �aa .rsm-- .w- r...- .��- 1a+...+.+•.. r -�ir�� Tr_- �_..�. Proposal approved Inspector's S r•� ture & Title to row 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 -,,. SIGNATURE r reported agent of Cl,�` owner agree to the above TITLE conditions. A DATE LZ 3 I UW: White MD); YeUjcw (fin EU; Pink (Aalicant)