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HomeMy WebLinkAbout0761DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 24. -1 -51 BOX 9 ,Iry a I Is to IN � 1 610 . Is Ir I.k'c IN IN ,: 00761 PUTNAM COUNTY HEALTH DEPARTMENT DIVISION OF ENVIRONMENTAL HEALTH SERVICES SITE LOCATION OWNER'S NAME MAILING ADDRESS PHONE OFFICIAL USE ONLY 06- PERSON INTERVIEWED PCHD Complaint # ame & Relationship (i.e., owner, tenant, etc. DATE TYPE FACILITY PROPOSED INSTALLER3c1(/0/&11;--3WT1' &��A PHONE `�` S��SE"'�7� �1 ADDRESS ayCJ 0o `i 4 J ,-.�, ��� �a ��. � REGISTRATION# f� � 1 8 5" ©— .4- Proposal (include sketch locating all adjacent wells): a��( 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 r po a gent of owner agree to the c6hiiitions "stated on this form. SIGNA TITL DATE-L:-5 �Q 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 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 Fp.. 'J cx /ST /MG 30 GPM YVF- LI O S B4 °07- 33 "'E �\)� coNN O / cAa a /vA 5O� X42 S F J�o � POOL -. L' v52°29 59 "YV is 77. 5pRING •\ . R /v C N N 0� /L 63 T � i• `F N. OLD �, , \Cif\ rn� o� N �I pp li � nj � /�OA1D•gEQ v ti ; X11 T/ L E F[ p 41 Z m lzr OC E '3 j0 '15 • 0 F PAyEMENT - -------►— N LE 0� .p o �C J� 0 o� Fp.. 'J cx /ST /MG 30 GPM YVF- LI O S B4 °07- 33 "'E �\)� coNN O / cAa a /vA 5O� X42 S F J�o � POOL -. L' v52°29 59 "YV is 77. 5pRING •\ . R /v C N N 0� /L 63 T � i• `F N. OLD �, , \Cif\ rn� o� N �I pp li � nj � /�OA1D•gEQ v ti ; X11 T/ L E F[ p 41 Z m lzr OC E '3 j0 '15 • 0 F PAyEMENT - -------►— N LE 0� .p o �C J� 0