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HomeMy WebLinkAbout0406DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 13. -3 -57 BOX 5 Is �� to its f� .' -, 00215 PUTNAM COUNTY HEALTH DEPARTMENT DIVISION OF ENVIRONMENTAL HEALTH SERVICES PROPOSAL FOR SEWAGE DISPOSAL SYSTEM REPAIR OFFICIAL USE ONLY K3 6 -o / SITE LOCATION g C� �Y 3 l 1 a�°D A TM #x`100 13.0 T 5 % OWNER'S NAMEV' ;r,n��� PHONE $ A X69 7 MAILING ADDRESS,- PERSON INTERVIEWED PCHD Complaint # ---Name Relationship (i.e., owner, tenant, etc. DATE /[b 3 io I TYPE FACILITY /fie g s e_ PROPOSED INSTALLERS a y rj,& e S P;P� i L S f Y-y'x C PHONE R 12 -,16 3 ADDRESS q 9 & A n,S a� ii1/►` ✓I t e 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. I, as owner, or, ported nt wner agree to the conditions stated on this form. SIGNATURE TITLE DATE / Proppsal 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 e. Installers' name and number. 3. System repair to be performed in accordance with the above proposal and conditions. Proposal approved_ Y Inspector's Signature & Title COPIES: White (PCHD); Yellow (Town BI); Pink (applicant) PC -RP 99ML DATE