HomeMy WebLinkAbout0881DOCUMENT CONVERSION SERVICES PROVIDED BY
IMAGING & MICROFILM ACCESS, INC.
www.scanyourdocs.com
631- 589 -8100
25.32 -1 -11
BOX 10
PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
pnnpoSAL FOR SEWAGE DISPOSAL SYSTEM REPAIR
OFFICIAL USE ONLY
9,331 -�
5S v,o A ,rrriri'�
SITE OCATION `
OWR'S NAME
MAILING ADDRESS
PERSON INTERVIEWED PCHD Complaint #
I , , ame & Relationship i.e., owner, tenant, etc.
DATE iA
PROPOSED INSTALLER
ADDRESS
TYPE FACILITY �:�--,I— ,
PHONEq(q�L,: 3_ - -7 F-5-5
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 frchitect.
N .e 6
as owner;-or reported a ent o owned gree to the conditions stated-on this form. - - -- -�-
'^ a
SIGNATURE TITLE "_g DATE i y
r posal 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.
Proposalapproved LN
Inspector's Signature & Title
COPIES: White (PCHD); Yellow (Town BI); Pink (applicant)
PC -RP 99NE
/ ,�-
DATE
IN at`�•.
We Propose hereby to furnish material and labor — complete in accordance.with above specifications, for the sum of:
dollars ($
Payment to be made as follows:
All material is guaranteed to be as specified. All work to be completed in a workmanlike
manner according to standard practices. Any alteration or deviation from above specifications Authorized
involving extra costs will be executed only upon written orders, and will become an extra Signature
charge over and above the estimate. All agreements contingent upon strikes, accidents or
delays beyond our control. Owner to carry fire, tornado and other necessary insurance. Our Note: This proposal may be
workers are fully covered by Workman's Compensation Insurance. withdrawn by us if not accepted within days.
Acceptance ®f P'" ropos 1 — The above prices, specifications
and conditions are satisfactory and are hereby accepted. You are authorized to do the Signature
work as specified. Payment will be made as outlined above.
Date of Acceptance: Signature