HomeMy WebLinkAbout0748DOCUMENT CONVERSION SERVICES PROVIDED BY
IMAGING & MICROFILM ACCESS, INC.
www.scanyourdocs.com
631- 589 -8100
24. -1 -27
BOX 8
�r
g.
a
EL 1 0
L
q IL
.
SITE LOCATION
OWNER'S NAM 4
MAILING ADDRESS
PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
TM# L___1
OMCML USE ONLY
J 6 -off
PERSON INTERVIEWED OW N tea_ — PCHD Complaint #
1 Name & Relationship i.e., owner, tenant, etc:,
DATE 1 -9a TYPE FACILITY
PROPOSED INSTALLER 01W K � L ��P99HppONE�S"r�) a218 -6-
ADDRESS 0 O (Z5 G9V TION# T-
Proposal (inc ude sketch l� co g a j cent 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.
k (T) %ki,w A*-LA wvJLJs
I; as -owner; or- reported agent of owner agree to the conditions stated on this form.
SIGNATURE D11f
',
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 comers).
d. System description (e.g., 1250 gal. Concrete septic tank, three precast 6' diam. X 6' deep''
e. Installers' name and numbev"'
3. System repair to be performed in accordance with the above proposal and conditions.
Proposal approved
�d 9 R-R!2-i
Inspector's Signature & Title
COPIES: White (PCHD); Yellow (Town BI); Pink (applicant)
PC -RP 99ML
DATE
I
SITE LOCATION
OWNER'S NAME
MAILING ADDRESS
PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
OFFICIAL USE ONLY
PERSON INTERVIEWED PCHD Complaint #
Name & Relationship i.e., owner; tenant, etc.
DATE _TYPE FACILITY
PROPOSED INSTALLER ..� 9vs- . rAre— PHONE . 11 '� Z7fI • 0
ADDRESS �— (J, , . d�� ,_ . REGISTRATION# 1. -/�-
Proppsal (include sketch locating all adjacent wells):
NOTE: Repair must be in same location and of same type as original sewage disposal! system .Different loc�jbon
may require submittal of proposal from licensed professional engineer or registered architect.
en n
I, as owner, or reported agent -of owner agree to the conditions stated on this form.
SIGNATURE TITLE rx-- . DATE_
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' diem. X G 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
COPIES: White (PCHD); Yellow (Town BI); Pink (applicant)
PC -RP 99ML
DATE
T � At,,, , I " a7
)4, Wet-..
ys
iJ
eyc- 2--?* CO
11