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HomeMy WebLinkAbout4694DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 91.25-1-1 BOX 35 ' I Is EI'6-� ■ 1 ■1e 1 se 16 f 1111 re k se ry se �. ., PUTNAM OQUNTY HEALTH DEPARTMENT DIVISION OF ENVIRONMENTAL HEALTH SERVICES PROPOSAL FOR SEWAGE DISPOSAL SYSTEM REPAIR OWNER'S NAME C Ana r, c"s S I �C6 I 1,nrl 0 PHCtNE J 2r -;3 U S— SITE LOCATION ` nn•• TO !MAILING ADDRESS ! 7 C , S �, t— :S't` .� �'t�f', Y� S / I 1 / �. 6 , On PERSON INTERVIWED PC HD Canplaint # Name & Relationship (i.e, owner,tenant, etc.) DATE TYPE FACILITY PROPOSED INSTALLER 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 from licensed professional engineer or registered architect. —t; . Wr_pllm ?`-� \ /_ 6 � . , .0<­�„ C'e,tp, / U ��Y1,1?.li/✓ �fiJ Ut. �— f VV 1� �_ .1 �i'! �/I.�/1,i -�. Cris �.-, i ,>t Proposal approved & T Proposal Disapproved Date 'roposal 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 canponents '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 perfomned in accordance with the above proposal and conditions. T, as owner, or reported agent of owner agree to the above conditions. TITLE DATE OCP26: Witie ( ) , Yellow (Tam ED; Pink (Appli®nt)