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HomeMy WebLinkAbout4717DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 91.25 -1 -28 BOX 35 T 1.16 r 04717 TD PUTNAM COUNTY HEALTH DEPARTMENT DIVISION OF ENVIRONMENTAL HEALTH SERVICES PROPOSAL FOR SEWAGE DISPOSAL SYSTEM REPAIR SITE LOCATION ` "t V O-T Ef " S OWNER'S NAME 8PLlya.L4 Z 61 MAILING ADDRESS /<e- W F t ,-5,'(--, ( OFFICIAL USE ONLY R TM# 51 V) 5 I— S R, PHONE 54r f-i- -Y 5'32S' PERSON INTERVIEWED PCHD Complaint #, _ Name & Relationship i.e., owner, tenant, etc. TYPE FACILITY 144- S DATE &/ 1 /0 z PROPOSED INSTALLER. �v F)- Q 9 UCc 4 & 4 (If PHONE S a 6 —o? S--q S O Sc6 w A N A d ADDRESS P� �-r�� U�4 c �y ��.C7�, lof?SREGISTRATION# 'F� �- (3f 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. _ - ..... as nwner; _ r reported a ent of owner agree torthe conditiormstaftAo -q. this, form. - SIGNATURE . LI'v4"t k TITLE 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 DATE l JOLI b. Site Street Name, Town and Tax Map number. C. Location of installed components tied to two fixed points (e.g.,house comers). d.. System description (e.g:, 1250 gal. Concrete septic tank, three precast 6' diam. X 6' deep e. Installers' name and number. 3. System repair to be performed in accordance with the above proposal and conditions. Proposal approved- Inspector's Signature & Title DATE COPIES: White (PCHD); Yellow (Town BI); Pink (applicant) PC -RP 99ML