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HomeMy WebLinkAbout0795DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 24. -1 -105.2 00795 IN ' ,, ` - i 00795 Sheet I of _/ PUTNAM COUNTY DEPARTMENT OF HEALTH __DIVISION OF ENVIRONMENTAL HEATLH SERVICES__ FIELD ACTIVITY REPORT NAM E& PaLL06-k Tel: 'T� ADT)RF4R: rf2.50 0/1 _ 21-2" P6 SOvL ti?. Street I Town State Zip PERSON IN CHARGE / ()R TNTFRVTFWFT). -17�W aJI 75 T)atP' / �L / / / oC, Name and Title TYPE OF FACILITY: Signature and Title REPORT RFC'FTyF,n RV: I acknowledge receipt of this report: SIGNATURE: 02/96 Rev. Title: n . Proposed'repair sketch Install "D" box, to control flow to lower pit } ex. pits 75+ yrs old I .. Pollock 14 �m-fer =4250 Old Route 22 Patterson NY well vd/1 'f4 ys J`r q 6;Y c SiMve.J 14VV4 LIvo C p6�jAc Install "D" box, to control flow to lower pit } ex. pits 75+ yrs old I .. Pollock 14 �m-fer =4250 Old Route 22 Patterson NY well oe- 'f4 ys J`r q Guest house Pond to be removed. r well 200 ,�k oe- f'2 ex. 2,000 gal cesspool, V- 2 area `in gray' to be removed. Replace with stone. i i'3',.cF., _,..` ,ion- x`a' .. '.rta. a a.._ _'° .� _n- t b e_Q Ct %R- t n S��ZS PUTNAM COUNTY HEALTH DEPARTMENT DIVISION OF ENVIRONMENTAL HEALTH SERVICES 1- 7NUMSEWTO SITE LOCATION q 2-S- -)-2. OWNER'S NAME o MAILING ADDRESS PX 6 �u' .1 ; o OFFICIAL USE ONLY # ? 0(0 PHONE A!. -- PERSON INTERVIEWED N 4 �_elr � Wh PCHD Complaint # ame Relationship I.e., owner, tenant etc. DATE 10 I O 1, _ TYPE FACILITY 1R mss,, PROPOSED INSTALLER ADDRESS REGISTRATION# 13 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 reported -agent of owner agree to the conditions stated on this form. SIGNATURE TITLE Proposal approved with thilomdag conditions: 1. Procurement of any Town permit, if applicable. 2. Submission of as built repair sketch in duplicate showing: a. Owner's name DATE � 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. C A . ep s Signature & Title DATE COPIES: White (PCHD); Yellow (Town BI); Pink (applicant) PC -RP 991ML FOR ADJOINING AREA SEE MAP NO .8 r — — — — — — — — — — — — — — — — — — — — — ~ —� \� N _ 1 Nk l n � LMNIIq AU ° � lME 50F j Z _ � V %_ � j •n / MANY 'w,r jl o %� wooneNtD� ep 1/\ i Ao .��� ^��• ( m �dMNyp7 q J . • y3snanos (HaAem UneJ �~ m � raver 1 1 o n - '�•��^ 6 Mannns r gg 11 (! (1 11 (I Q 11 R (1 11 R t` 11 1j 11, (j. 1}. Il. A �JJJJJJ. �JJJJJJ�JJV' utJUVWUVUVWW .V_V_�I..WUVV_V.uV�JJ�JV�IV ca o B N N aACN C11 W 8� 9d�0s�00 ®�• L CD *a t < a c 4AGN I NGF' f p0 °°� MLL AC J i°8 Of r: \ ^�,