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HomeMy WebLinkAbout1072DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 25.54 -1 -10 BOX 11 01072 `ri LF� 01072 PUTNAM COUNTY HEALTH DEPARTMENT j DIVISION OF ENVIRONMENTAL HEALTH SERVICES 225=0310 PROPOSAL FOR SEWAGE DISPOSAL SYSTEM REPAIR -1�1 8 3 OWMIS NAME :. } �I �S Cook PH= 9279 g SITE LOCATION MAILING ADDRESS �� D �L � 09 Q O � � P/4 �Ei2S'o A) ik) � /*t s lc 3 PERSON INTERVIEWW PCHD Complaint # Name & Relationship (i.e, owner,tenant, etc.) DATE TYPE FACILITY PROPOSED INSTALLER PHONE 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 'ttall of pro from licensed professional engineer registered rcfiitect� A A/ 1� p % -V-M C n YA e LCD 1h 4�T) 2. 3. '1 Proposal Disapproved 2-'C D' to osal approved with the following conditions: Procurement of any Town permit, if applicable. 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 canponents tied to two fixed points (e.g.,house corners). d. System description (e.g., 1250 gal. concrete septic tank, three precast 6' diem. x 6' deep, drywells surrounded by one foot + gravel). e. Installer's name and number. System repair to be performed in accordance with the above proposal and conditions. I, as owner, or reported agent of owner agree to the above conditions. . SIGNATURE C(. — TITLE O DATE 0- S Z9 33PIES: *Ate MD); Yellnw (Toon EU; Pink (AR21CM10 f Teo 74t, 4J io 44 I I 7(o,f r,t .L ���f 2 Zrd�FI I I ; jz,4c) ; . .. X784' O' F' SOW 1�o°LiD �F "Lie- 100.E CAD - It tiPty -7 C., 4- -35 1 -71o34 7 33 7(,.32 h" ► ouL zz.� I S�eV f W 7(,57 I 1 24.43' -76, �5 1 J v I, I I I I V1 o, +QOM {f� O4'• SG' F- PE LMA12 �i �7U2VE,Y OF \\ PQO PE.CZ T \ P2-EPA2E..C� p FbO /+ JAAA�i A. k I,...00UA AA. 1..001- III l.. ®T Uoff. -MU - 74,a3(o A,i 51-10 w u o I E.(GNTN AAAP bF PUTUAM LAZE- FILED Wt WO.ILLS)G PILE- 320.31 T01a U OF. PATTE.Q--?OU PUTUAm Co. U�( /7C.&L-F. 1 "-20' JUl. 4 280 19ZZ CkEZTIPI D - -TO 7-AF- OAT IQI-IAL P.,,ALiI- OC �1 TCµESTEP AUI] ib -NF �EGU21T/ Ti7Lk at->AQAUN Cok(PALrV Fog TNEIG I IcY uo 2GP 5O9asG. CE.2TtCICA'TIOLJS IUDIC -A-iE� IiEP.E10t.1 $IGU1� TlaA7 NIS eL)b&V WAS PI EPAMCD lu ACCOO"AL.10E. VM T1E EX15T(LIC, CccE CG PeeCTICF- Po LAUD 5�e\lc -6 AI'OPTED lak THE L*-VJ tibeK SVVF -. IQTIOLl or PMCES610"PL IAM WeT -`bE a. SAID CEiTPCATIOL[S -A*LL 1?UL1 Olil_V lD -1E P� rC UI1w TWA 1 ,bow V tS PtepAZED k4m ou ws er --AALi 7- -TrTL% ccupk ,l AuD L4mf ILL(, 111StrTVTtoL1 L.&� 'OF -UOLI_ Ct✓ZTJF C.A.T10L15 m. L1bf TeA TE.CA&.r. -To �ADDtT10UAL lusTITIJrIOUS ae. S.*rst-GU okllr--eS. T T7+ • �i _ — .f.��r uL1At�Z �0eIZ F� ALTE Z&TjoU ce I.ADDrr ic.0 TD TMs mAP iS A QIOLATtou OF -ckC,notj 4=5 <p 'ME U�-r Vav- StME ED-xATIOL L.AU. UUDE2C@x3L b sreu .TUees, LF A!-IV. UOT SWC)WLI. ALL CEQTi CIC.ATIOL LIEQEd -I A2E \IAUD Re 1)15 UAP A►1D CoPCh OWq tt' sAID WP oe CDAes EF: Ae -NE llA D SEAL CC TOE SUMEVCf 'wUvSF- SIGUATI�E AT'Fr<AeS >aEf2Ed 1. t'�2GE{1CA2GF- ISI E- WdU BEET C-3��.+..(51C -.rte, U•`i. �...