HomeMy WebLinkAbout1160DOCUMENT CONVERSION SERVICES PROVIDED BY
IMAGING & MICROFILM ACCESS, INC.
www.scanyourdocs.com
631- 589 -8100
25.57 -1 -19
BOX 11
q t
ioil
F-- El It dw
01160
PUI'NAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
225 -0310
PROPOSAL FOR SEA DISPOSAL SYSTEM REPAIR'.'
OWNER'S NAM, /%%/ ( ctw/wkz PHONE
SITE LOCATION If t/7 , S6& 0A-- d / 5r 7M#
MAILING ADDRESS
PERSON INTERVIEWED PCHD Complaint #
Name & Relationship (i.e, owner,tenant, etc.)
DATE TYPE FACILITY
PROPOSED INSTALLER Q�: ,.. - 'r ,ei-3Z �yzz�� %sec - PHONE G1(t- 7-79•
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. F
�i [!c !a` ..: 6 >✓ s_ : .� _ ice. W-1 WA
Proposal approved ~. PProposal Disapproved
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 canponents tied to two fixed points
d. System description (e.g., 1250 gal. concrete septic tank,
drywells surrounded by one foot + gravel).
e. Installer's name and number.
(e.g.,house corners).
three precast 6' diam. x 6' deep
3. 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 TITLE DATE
C/
OPM: White MD); YeUcw (Tapn BI); Pink (Appl.iaant)
9 d�
-ja?"-31V
(D-,
m