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HomeMy WebLinkAbout0095DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 3.19 -1 -22 BOX 2 00095 u fir, T 1T 1 f - ,, L� 4n. JIM 00095 PUTNAM COUNTY HEALTH DEPARTMENT O W/ O 0 DIVISION OF ENVIRONMENTAL HEALTH SERVICES PROPOSAL FOR SEWAGE DISPOSAL SYSTEM REPAIR OWNER'S NAME ,?,non &ncd %-I- PHONE SITE LOCATION 3 - /72.; 7W p /%r o.► 1 63 To `" a MAILING ADDRESS Sync . PERSON INTERVIEWED PCHD Camplaint # Name & Relationship (i.e, owner,tenant, etc.) DATE 7-)-7-,Pc TYPE FACIILITY h Mt. PROPOSED INSTALLER „ -QA4#; REGISTRATION # Pro (include sketch locating all adjacent wells): NOTE: Repair must be in same location and of same type as original Different location may require sutmittal of proposal fram licensed registered architect. 0 PHONE 9111- �s 373 sewage disposal system. professional engineer or `e A.) &§ J-4 4 ".1 0J. Proposal approved Proposal Disapproved Inspector's Signature & 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. 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' diam. x 6' deep drywalls 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 owner agree to the above conditions. SIGNATURE I 4��/ TITLS DATE PM: indite (MD): Yellow /Min ED; Pink (Appliamt) �� i 3 � �y 3�� �- � � . s� � �z`