HomeMy WebLinkAbout1149DOCUMENT CONVERSION SERVICES PROVIDED BY
IMAGING & MICROFILM ACCESS, INC.
www.scanyourdocs.com
631- 589 -8100
25.56 -1 -74
BOX 11
01149
PUTNAM COUNTY HEALTH DEPARTMENT'
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
225 -0310
PROPOSAL FOR SEWAGE DISPOSAL SYSTEM REPAIR
OWNER'$ NAME
SITE LOCATI%
?HONE
TM#
K -g - v
277-o
MAILING ADDRESS
PERSON INTERVIEWED PCHD Complaint #
Name & Relationship (i.e, owner,tenant, etc.)
DATE TYPE FACILITY
PROPOSED INSTALLER Z4g; Q A- on rnAco PHONE2o3
Pro (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.
.� D � /�' G `e -°S d� � i � fd �! � G! v7 r►� / ��! S f 0 �� e� 'A/ d/ l/ �o'r9g /
-010r-
Proposal approved Proposal Disapproved
3
I Date
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.•Systen description (e.g., 1250 gal. concrete septic tank, three precast 6' diam. x 6' deep
drywells surrounded by one foot + gravel).
e. Installer's name and number.
3. System., repair to be perfornned in accordance with the above proposal and conditions.
I, as owner, or reported a ent of owner agree to the above conditions.
SIGNATURE n a TITLE DATE
'ES: W-dbe (PAD); YeUc w (m HI); Pink UVPlicant)
4