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HomeMy WebLinkAbout1064DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 25.49 -1 -9 BOX 11 01064 69 1 1'L `� ♦� '� 1 �., ` I L. _ , 01064 SITE LOCATION OWNER'S NAME _ MAILING ADDRESS V PUTNAM COUNTY HEALTH DEPARTMENT DIVISION OF ENVIRONMENTAL HEALTH SERVICES OFFICIAL USE ONLY - &09 -o,sr TM# 6k-, 0 --/ - C'1 PHONE PERSON INTERVIEWED PCHD Complaint # Name & Relationship i.e., owner, tenant, etc. DATE TYPE FACILITY ,, . PROPOSED INSTALLER 29-97,c�r' Lea✓ PHONE S x•2 e ADDRESS �09 S 6v X �a r,-2, Al Y. REGISTRATION #_ P;_ 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. z 6' a&-owner; or�reported a eqof owner -agree to the�conditioiis -stated-on-this-form.- - • -,--! SIGNATURE ` TITLE P=- DATE 7 ' 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. Propo prove , hj, 0� Inspector's Signature & Title DATE COPIES: White (PCHD); Yellow (Town BI); Pink (applicant) PC -RP 99ML .., i --'.,jt- I ;P � �;,+ N, � �, .% 4�` , ; , 1�' ,­`� im,,�,, ,'" � "-"7, "' t �� �',.�' ,.-,T� � t'l.", -;�:�I�,'�"`�",.,* 'I �_��'.�`�"t:�i�":�;; 4 . ­ . ��, `z , �.11,111� :1r � " '. `:I:l t'i��;, '.. . , � , t 4F . 1. 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I � - - -�, * "i �,,,� , L , , � �. ��, ("V Tv"':Lk - .w PA, ­� - - — � � �.) �� , Yx s 1 - , " SITEI'LOGA li . ), ­n' 11, C�- ,.'' -� ..��,Y:.. , , . 3,i��'. . , - I­t� - ..."; 'i�liklt ., . '.,i .:� A, ,,, , , " - "I'll..-, �4,A - I �!,,�'� ; 9,w: I" . .�`. � t ,Ia�� i ,.,� .�t, e ,- I �� 11 � ; " , .�- ;,. ''... VJ-;?V:� , - ., 4, ,� �, ��'. . ­: - I I "It-9. . f, - I -) � ... , , . - - � OWNER'S. I 1, F i��O�J(,(__ ", - .� . , ,,, :4; ADDRESS , (! 11 - �,;c 14 -1� ­0 .- q1, t , 11:�� .1, �, 10 _' �'. 1� A. � ��.�, . �(,: 1! 'j 1. '' .1 � - � , ,��V 4 z . � -?,: "IbY ... MAILIN6"ADDRESS' e��"' I 4 )c - , - I * I I -'� ' - . ­_ t._:-.,:1.�... ". i,'.�,,,��i��,',�', I , ­&­"­..� 11 ,I " . .,�. ,� 'i ., j ",:1, -�%�,��, I I , I "' , , ­V. � . ��­. qr"' , ­ , .� _ , " : �­ i� * "it. �.,." ztf "i ,I.V,� r , � ., � I .� .4 .. ,, '111`1A ­,­', ;'-�. ,,�,. '. .,. ­ - ItI. 'A INTERVIEWED1 _­".k. . , ..� , PERSON ­ , � - , , , . - Ii -tr e�. ��;J-.', �4 `S_-7_� e.& Relationship (i. I t, , ,�, �_ i", - - � , , ", - .. .. f �, V . """' V� � ,:,tt'- ,� .1 . ,g.,�.ownerjenan , - 4 � -S 41 , it.;�Q,!.,;-:;'A4 .. , , ,L .., �: ­ I T, i! "MA" �­!H'! A.4 !.. , , � "t I It- I ; ,­, ., J. A "I Z, il - � L �`,�'t' "tt';�'�,F,�t�,.Lj.-,.k�;� �ti,;, tro �­ ?J , - - �, -.6 , .. , "' - ft�-�n : I .11, 14 ,q: ,,,-, �!, � *, P - , , ­ �_ I � , DATE ,� t;41"-,��t,)jn .,I ­11� -,­', ­!�t'�,,.,­OtL ..�I'l�7",,�gii��.,,,,,��,4,�, k%_ ... - I , " .� "N'. . ''. to., - t�� a t. � _111. ) �,-A, " '. .- t � �,4. A 4�,','� , !" - , , 1".. 1;.� _,: * -1 * "i `1-�-, , - -AJ I I - "' ^ . I ... . _-.� I � tt "' 1�' .l.t. . .� � � .;.� -I' . .� . �.I� Ni � (L4.�' .� t� .. �: ";,"e'., PROPOSED INSTALLER "I.� i ` I I - Ic - 1-: � �. - - , � - I I - :­ � -, . �, Z �� I., I ;� ,,- . I 411*t � . 1. � i � L .a , , � r t 3* q,.,, � ", ­tx,, ­­ ", - - - ,:..... ­ ­ 1, I , I I 1: _� _'� '; _t"; , 1, -,I' i, � � . I I 1­' - 13 -� 5"A�-Ii.�*_, - � I 11 I .!�� — .f ­'t t, - I . A ;- r 1� 1. 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I 11 -r,�,- K 7, 7�". ., ./ 0� .� �� �� . 101, CIW�XTA'M MV' /� _, ,., ., � L.TTTUR -- / , . - , 1� .-'.,Il','.�,'�h'..,.,..�..-i,.,.',��,*.-,',.,,,., , _. -1 * I following; . robo P, " sdtabnroved with'th6 'tt66hd1t1Mk..1 , � - - - _ r�.,"�4ti;Lf-. 4. Procurement ! �, _7_.�. �' �- - � ., ­� ,�-. .- -_�� ,Zt-1 '. - �--�`� ""I . . F�34,- i. �, ��i� ,,,�- I ot any,J own - J�. i�irniij�`-'dapliheike' It j ,v - . t� tg �4, , 1. ?�,.. ,� ,.. . '. , ,i, permit, " .'m f I 1, -�j ,,, . I " If, ' Submission * ,*air sketch in duolicMe showing: I-1, �; 2.*­,ik�k o . as repair � �, w - . - I� . - , . , . , , " , . .t. -, - .- , .; .- -,.*,-' ,�., " i�! , I. '.I f� t, : 1.��,�",". �e �i -,I V "­ I I. I . 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