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HomeMy WebLinkAbout1209DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 25.63 -1 -21 BOX 12 I I ,tiL I , MIN 61. , , IL L L �I 01209 PUTNAM COUNTY HEALTH DEPARTMENT DIVISION OF ENVIRONMENTAL HEALTH SERVICES PROPOSAL FOR SEWAGE DISPOSAL SYSTEM REPAIR OFFICIAL USE ONLY 40 ----3 SITE LOCATION, L c{ &cb or�'" r I "' `�' TM# c� % op ;Z ,Q —off OWNER'S NAME kJ 1'cji a e J J n ? ±jEi Se.e -__ PHONE 9 ,f{ -I 7ef A. MAILING ADDRESS J3 La Kzo& o rf-_Dr i ✓e fit *-, 1-,5 o ry y V U SD. I— PERSON INTERVIEWED ' , b ct P. f J �� - PCHD Complaint # ame & Relationship (i.e., owner, tenant, etc. DATE _TYPE FACILITY Li PROPOSED INSTALLERS r� PHONE A © 3—Z#'6 ADDRESS 4. � _L 1 inn Rd N.F Lam- 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. .:.e'. --- /-:, I, as owner, or reported agent. of owner. agree to the conditions stated on this form. SIGNA TITLE Y- 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 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 _� d ' Inspector's Signature & Title COPIES: White (PCHD); Yellow (Town BI); Pink (applicant) PC -RP 99ML a C-0 j a h ct ~ Ho —(A\s ef.", � ` o - r 1 M V V O o o SE,E h�ous� ? 5 L A- K tc...o ,AT 0/1