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HomeMy WebLinkAbout1159DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 25.57 -1 -16 BOX 11 er re 16 sm'6 01159 Ar SITE LOCATION °- OWNER'S NAME MAILING ADDRESS PUTNAM COUNTY HEALTH DEPARTMENT DIVISION OF ENVIRONMENTAL HEALTH SERVICES PROPOSAL FOR SEWAGE DISPOSAL SYSTEM REPAIR OFFICIAL USE ONLY �C /Vir —�/ ; 7, 7— /, oil PERSON INTERVIEWED 6 TM# .2 �— . J , PHONE Z7 <6, OV7 PCHD Complaint # DATE r JjJ�I • '�4 TYPE FACILITY_ PROPOSED INSTALLER .� c� C'�-/ A PHONE ADDRESS REGISTRATION# 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. owner, or. agree- to- the,conditions. stated. on this form.. TITLE 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 DATE lO - ;?-5 • ©/ 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. Proposal approved _ Inspector's Signature & Title COPIES: White (PCHD); Yellow (Town BI); Pink (applicant) PC -RP 99NE ATE 11th �• �! FAIMtFIEID,CT 06812 i � —77— P1'opt�°� -y L ov 2� fib..». Z).-al/ 8-11-S - 2 26 - Pa 7S 49.21' N C. B. RET WALL .. t I * 1 14.4 rF= I 1.7I T 8.5 F��RY tn ))8 7.8' ao 10 R = 205-089' 36.32, LAKE' SHORE.... DR. U MAP OF -PROPERTY SITUATE AT PUYX4M LAKE TOWN OF PATYFRSON PUTNAM COUNTY, NEW YORK ROW SCALE I" = 16' TARRYOWN, N. Y 10591 JULY 15, 1994 BEING (914) 6.31-4232 LOT AlAe 9648 b 29AQnfJ A rFPrAIIJ up rhm rn 'FOURTH W OF PUNW LAKE, PUNW COUNTY, NEW YO) 17LED IN THE COUNTY CLARKS' OMCE AS W No. 149- C&MM TO: 9WUa AND M4 LARA ACOWS ABSTRACT CORP. STATE OF NEW YORK MW=GE AGENCY, CIO ARCS MORTGAGE NC, AND OR W SUCCESSORS OR ASSIM 94MM MW INSURANCE OF NEW YWK ING ONE STORY 6) FRAME No.272 JOHN I MULDOON, L.S. SURVEYED AS IN POSSESION 77 TAPPAN LANDING