Loading...
HomeMy WebLinkAbout1190DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 25.62 -1 -51 BOX 12 I ,. -1 -w y I = '.�j :;� how I ■ .. ■ Ti ■� I ' T ' I `� , 'i, o ._ 1 . f �I 6-r r 't.010 ,,1 11 y 01190 PUTNAM COUNTY HEALTH DEPARTMENT DIVISION OF ENVIRONMENTAL HEALTH SERVICES PROPOSAL FOR SEWAGE DISPOSAL SYSTEM REPAIR a*MI S NAME / "M 6,16M -,Q PHONE SITE -LOCATION S,�'�� �A !f A,' ?�' ��,ri 710 5 , 41) MAILING ADDRESS Arnrl 11s --� °�r PERSON INTERVIEWED PCHD Complaint # Name & Relationship (i.e, owner,tenant, etc.) ,� DATE TYPE FACILITY l £ � z'l<f -z- PROPOSED INSTALLER G >r ?a�� �ci`� mac; �. PHONE REGISTRATION # 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,fran licensed professional engineer or registered architect. Proposal approved Inspector's Signature & I Proposal Disapproved i ronosal aonroved with the followinq 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. �F sb (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 Wn!S: %bite (PCFD); Yellow (fin BI); Pink (AP}aUawt) RN tb V/ C�8pS O e s G boo PR ,/1 l- q� 0) - v J L5 T 1 73o-y PbX 13oX �.� kox 730 r boy ANTHONY LUONGO INSTALLED BY: BOTTGE SEPTIC, INC. 26 SALISBURY RD. SODOM RD. PATTERSON, N.Y. BREWSTER, N.Y. R- 118 -92 MAY 15, 1992 (914) 279 -6069 , SITE PHOME - 1 V TKO MAILING ADDRESS 'FO'' PERSON INTERVIEWED PCHD Complaint # Name & Relationship (i.e,, owner,tenant, etc.) � DATE TYPE FACILITY.�� PROPOSED INSTALLER' PFIQM Proposal (include sketch locating all adjacent wells): MM: Repair must be in sake location and of same type as original sewage dismal systwo Different location may require submittal of proposal from licensed professional enginew or registered architect. 1 Proposal approved Proposal Disapproved roDosal amroved with the followincr conditions: to Procurement of any Town permit, if applicable. 20 Submission of as built repair sketch in'duplicate showings ao Owner's name. bo Site Street Name, Town and Tax Map number. c. Location of installed components tied to two fixed points do System description (eogo,'1250 gal. concrete septic tank, drywalls surrounded by one foot + gravel). eo Installer's name and number. 0 (eog,,house corners). three precast 61 diam. x 61 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 ��� � ATE cyt -- XRMSs ftte WD),-, Yellcw (Tam ED; Pink (Appliamt) N -7 d 14 Ll 0 '70 fort kA ,n1 M I ILA 6 A Aetz- aSad AFT <,a-W2cVx4 Fox- gzww&,4,,- -all ew (0 i