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HomeMy WebLinkAbout1088DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 25.54 -2 -18 BOX 11 r , Is I' I% �` _ r or I UP PUTNAM COUNTY HEALTH DEPARTMENT DIVISION OF ENVIRONMENTAL HEALTH SERVICES PROPOSAL FOR SEWAGE DISPOSAL SYSTEM REPAIR OFFICIAL USE ONLY `\ - a g -05 SITE LOCATION PAl(-44VA TM# Z- 6-V — Z ^ 1 A OWNER'S NAME LAyK.A 6LA �.,< i - r An r5 PHONE & :7q.. g2V-V MAILING ADDRESS 42Q OA ca2g. WL ­ Pdfibrsc� , A-(-Y • 12-M3 PERSON INTERVIEWED PCHD Complaint # Name & RelationshiD i.e., owner. tenant, etc. DATE TYPE FACILITY )6<- . PROPOSED INSTALLER ! ( F �,Ue_ PHONE JS- Z "l 9 ADDRESS Sc►& c.N REGISTRATION# PC- 44 , A 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, oor.reported.agent of owner agree to the conditions.stated on this form.. . . SIGNATURE IVL�Ice�"LA— L TITLE �,vtc� - DATE-3---L Proposal approved with the following conditions: I. 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 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 bg- performed in accordance with the above proposal and conditions. Inspector's Signature & Title COPIES: White (PCHD); Yellow (Town BI); Pink (applicant) PC -RP 99ML c 2� nf� DATE c I ,v - °�✓ Iii 09 0 L_A" t.p, 4 u -ZG is AAJ tP `" LA;DXA- AJ Z-,79 (00 (09 . .. SaorrL ��►-- .26 -' � �Z.,'� N �zs� �• Z41 6%5 PUTNAM COUNTY HEALTH DEPARTMENT DIVISION OF. ENVIRONMENTAL HEALTH.SERVICES �Z 190 OFFICIAL USE ONLY SITE LOCATION Ocl r�, c� ?,�c�) TM# -2i --2_-1A, OWNER'S NAME t 1.i 1.t eu 0,uEr r -L)1M 6 PHONE AK-.Z?f • qtW MAILING ADDRES PERSON INTERVIEWED PCHD Complaint # Name & Relationship i.e., owner, tenant, etc. DATE TYPE FACILITY PROPOSED INSTALLER`, PHONE S�/� ADDRESS*) �� . -a, ., , Z A (� j REGISTRATION# ?U 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. &fL- _Qaa2KC_ lb Lps��y IV16 &_X�_ M, d&1r.U9_ C07y), ALI�- /I�tu -L6,-k- fi,A2 vii �'�1$nr, C,'n.2M -,CJs = a- ti�:z.�i T I, as owner, or reported age f owner agree to the conditions stated on this form. y SIGNATURE ��� TITLE DATES % /?' a-S Pro op sal 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' dame and number. 3. System repair to be performed in accordance with the above proposal and conditions. Proposal approved 3 �© Inspector's Signature & Title DATE COPIES: White (PCHD); Yellow (Town BI); Pink (applicant) PC -RP 99ML L X-A- (SCAB o va 7'IM � a.� •st(- Z- l� COO /2.310 X w. q1to c4u L> ,� Ica � �i,�c• ��. � ,C�.�,� S�sr� � t viland 0 llow c v -.65 00 KEN J r?-LE 99 Z U 66 D LA M11111 y Is I Ui Z"/, Z 0 66 D LA M11111 y Is I N&J -23 -2015 0 :'11 FR0r1: FU'1 NAP' LUU N I r Ut1-HK f PUTNAM COUNTY HEALTH DEPARTMENT DIVISION OF ENVIRONMENTAL HEALTH SERVICES 0MCUL Ust ONLY ITE LOCATION �. •' . •, ' J o•O A PHONE inn ± / 'ERSON INTERVIEWED PCHD Complaint # "Nnme&YelatTonship (i.e., owner, tenant, etc.) )ATE TYPE FACILITY ?ROPOSED INSTALLER �,�t� _ PHONE 6�� -�1. (r¢ ADDRESS . ilM�,(�. k y � , , - - REGISTRATI NO Pi-oposal (rncludc.sketch iocaring all adjacent wells): NOTE':' Ftepatr.ranust be,ui same lQcatton anti of same type as ongnal swage disposal 'system`.DiBrent location may require submittal of proposal from licensed professional engineer or registered architect. rlLJ . J G r , I, as owner, or reported age owner agree to the conditions stated on this form. Q SIGNATURE �t � TITLE l�.Gj----- - - - - -- - - DATE -d—'_LL Propos aR roved nth �11� f41�1�g cones 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., 1256 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 Vproposo.and conditions......... . ` Proposal approved Ze:a I j� �A f/F'jti�' sjl t ni. , I' t •� f. 7 Y Y , i 1 . 1 ,._ Inspector's Signature & Title DATE COPIES: Whito (PCHD); Yellow (Town BI); Pink (applicant) PC -RP 99ML 4 �� � � �i"�>: .r�'3 ' � its t \c'i�'' Y � t 3t _ .�_ ... ., � ' ��1�E is