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BOX 33
04364
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Name & Relationship (i.e, owner,tenant, etc.)
TYPE FACILITY
PROPOSED IIZSTA._�R �G T PHONE �Li S-'l S--/ S `y
T.T � m
REGISTRATION # -7 ,4ce,a-
dal (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.
Proposal approved
2.
3.
's
W
ture &
tle
Proposal Disapproved
wal approved with the followincr conditions:
Procurement of any Town permit, if applicable.
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 cauponents tied to two fixed points
d. System description (e.g., 1250 gal. concrete septic tank,
drywells surrounded by one foot + gravel).
e. Installer's name and number.
ti.
Date
(e.g.,house corners).
three precast 6' diam. x 6' deep
System repair to be perfonned in accordance with the above proposal and conditions.
I, as o� ,\ r porter -a? of owner agree to the above conditions.
DATE
SIG t'_`..._""--- --- TITLE
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ME: ft be (FW); Yelic w Ck,An ffi); Pink (Aftil rt)
PC -RP 97
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Application
11111tnAo:p ty
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Date ............
..........
n r Cod
above
Town, e undersigned hereby' makes APPLICA!
�t install A
..................
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M.Waiae, brX, 'Imer.
im
I Addk SPACE
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24
UM 41
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FOA
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yg e,� . ..... . ... ............................
SKiTCH
. . ... Sq. Ft.
.--uP�WO- Of Pedple. exPftted
�-to use fpcUity ...............................
Date installation *Wibe started ................
M ...................................
M077CE: A 33LUE
PRINT OR: SKETCH showing (1) boundary .11 es pr Pr
Wells clsterni, springs, etc. (4) proposed location of facili�y, ffincludin
APPLICATION:
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Name of Plumber ............ ..................... I, 4
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P. •O. Address ................................................._ ..................4..r.........
Signature ' of Ap
plicant ....................... .............. ....... -tl
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CjO 0900 ---------- n ------------
4
TOWN OF-P'uTNAM- VAUAy, Application
4qtni a County, New �*Tork:'
..................................... ..............
Date ..... . .............
4 • Pursuant to the provisions of the Sanitary ry Code of the T
oyfr�—I hhereb acknowledge the RECEIPT. of ten
dollars wd.doj with the. application of IC4
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.1T0;;; Clerk
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Name of Plumber ............ ..................... I, 4
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P. •O. Address ................................................._ ..................4..r.........
Signature ' of Ap
plicant ....................... .............. ....... -tl
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....... �44
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CjO 0900 ---------- n ------------
4
TOWN OF-P'uTNAM- VAUAy, Application
4qtni a County, New �*Tork:'
..................................... ..............
Date ..... . .............
4 • Pursuant to the provisions of the Sanitary ry Code of the T
oyfr�—I hhereb acknowledge the RECEIPT. of ten
dollars wd.doj with the. application of IC4
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. ............ .
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.1T0;;; Clerk
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