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Home My WebLink About1145DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 25.56 -1 -65 BOX 11 Ills '' ' IN , t ; r I Ir I 9L46 1 6 loll IN 6 r, 79 Flo am ML I 01145 y„ PUTNAM COUNTY HEALTH DEPARTMENT DIVISION OF ENVIRONMENTAL HEALTH SERVICES OFFICIAL USE ONLY SITE LOCATION (G t A(OrV14 0A I y P TM# OWNER'S NAME C, '7© 0 a 0 i S � i c�r�� PHONE ;7q, J CJ.V 'i MAILING ADDRESS 1(b �AcoIV4 Q9tvE. DA�QRDti � 7aZIE `3 PERSON INTERVIEWED PCHD Complaint # ame & Relationship i.e., owner, tenant, etc. DATE TYPE FACILITY PROPOSED INSTALLER ` j ,.5r= p4 ,/�Q� /�¢ PHONE °3; '7$ 6 , ,90 `7 ADDRESS k3 'ZLLl,4AJA(; A)(�u,Jr- ANt7eci7; C—/ REGISTRATION# PG 144 `% 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. lV I,:as owner, or reporte At�qw;neLagir -ee.to the conditions stated on this_form.. . SIGNATURE TITLE DATE C 1 _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 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 Inspector's Signature & Title COPIES: White (PCHD); Yellow (Town BI); Pink (applicant) PC -RP 9%E I I � 1 Q) O I I LgCONA 0 C nl Vj �S A n t, 0 0 o, DRIVE •ne,�nm.I• ��ql .,�9•p3'10„ f .90.00 Df � hL..r..tonn�, tAIA 1_L 773.46' S1,l '10,20.00 5 U RVEY OF_PROPE_RTY 1 ?1U PAHEV !U /1 u Al�l�xii� IL111,D1 A 11VI O A CO —51I UA T_ E IrOWIN OF /PAINT /ER� �D / IRU/TINAI+M / 6701 /,' Pr INIEW >YAOIANK SCALE_ /rvcN= 20F£Er DECEMBER 11, 1972. G/snnOn J. W01son, IAS surveyor meoo �Oecembe p%/�197Z 1ha11hs, this survey shown Aerson ws completed, by mop was comp /sled on December /2, 1972, and """ ,/ ws prepoI . In accordance wah the exrsLnp Cods o/ Piocl/ce /or.Lond Suiveyt oo VIVO`. by The Nmr Yarn Slur. Assonu/,On Of golessmnal LOnd Surveyors, The Ihrs map is so cerNlmd only 10 Al. K' and Linda Monaco, Lbunty,Trus/ Company, The V. /.ions Admen /s /ration and rho US. Li /e rifle Insurance Company for 'is rate NO 130152P. G noon ✓. Wolsa , L.S. NYS. Lrc. NQ 48167. ,Ae e7 O rrr /I f LA N p� t%%% 0 \0 NOTES /. Alterol,on at /his document, except by o L/censOd Lond Surveyor, +s 1 110901. 2 All CartlfrCa /tans are Valid for this mop and copes /hereof only ;f /he said mop or copies Door the impressed seal of the surveyor whose signature appsois hereon. 3. The promrs,s hereon is Lols 5694, 5695, 5696 and 5697 as mown on Mo/ certain pPo! unfitted EtyldA Map of Pu /na n+ La-to, ... h,ch ros filed ,n rho Putnam COUnIy ClOrks O/!rce on March 20,1931, os Mop NQ 149 -G.