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HomeMy WebLinkAbout1214DOCUMENT CONVERSION'SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 25.63 -1 -35 BOX 12 I ' ' ,' ' ,�� �: IN 06 ;I �N IN f b h Nd 0 Jr 01214 SITE LOCATION OWNER'S NAN MAILING ADDR PUTNAM COUNTY HEALTH_ DEPARTMENT DIVISION OF ENVIRONMENTAL HEALTH SERVICES PROPOSAL_ FOR SEWAGE DISPOSAL_ SYSTEM REPAIR OFFICIAL USE ONLY A l f of *ees an TM# y1s c 1-117 '411 k, +Tens r PHONE 9l H AN) -31n5 ` PERSON INTERVIEWED PCHD Complaint # Name & Relationship i.e., owner, tenant, etc. DATE TYPE FACILITY ,3 PROPOSED INSTALLER_ 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. as owner,: r p rted.aent.of o►rter.ae.to.th? co�+ditio!+�s stated on this form...'. SIGNA TITLE DATE Proposal BDnroved 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 naive 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 G 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 DATE A� 0 'Date_. Mart L ..... . . ....... ............. ..................... V 7 77' , UAM C* U T".1Y.", PUPTN" "M; Mil Y. i. A lSewa InstalMon 6T e is.posal,. Facilities ppi or i ' }'i , }" Fe ,- 'of 147;5 cc The undersigned ebyl makes application f6F ap certificate ;i W proval of and "a cert for the installation of S t et a;7�� C#s*ipool E] Chemical I Toilet ff Privy E] property on the prop. dekribed- below. Location of Property - Y ?.1 ........ tt -5 _19,1:AV Villages Subdivision,, ....................... ; .... ........... ock No. Character of building! Dweilinj"�`�' No. of Occupants_ B6drooms..'.%;V-' ........ :taihs'... ........... tx b�' ...... . ...... Garbage Disposal Sink ...... ........... z ............... ..... Automatic Laundry Washo . -'Source of Water Supply !Public ❑ D; I)p filled Well] Dug Well.❑ Name of Owner ........... Address ......... Diagram showh4g, l4cation of proposed''installation on property. adjoining property line and distance from nearest water, watercourse or I within 200 feet.-Also sho location of dv�ening,,.- or building to be seiied)±. CA Tank 77w 7 Q 7 ?: io:-pe; r�di Corrections, If .any, to be m4d e, -74; "M 6 u bee oZt .............. inspector General Contractor_ f J i i y'.., j Address ....... : .L.. I certify that I ha"'in'sp6cted the facilities Called ior, in the foie same are installed Ns shown In the ftgrwi there'on with the ch comply with the'se*age 'regulations of theTbwu Board of Heall hereby grant this CERTIFICATE OF 00C1VPANCY. Premises were Inspected on� ihe! fohowlng dates Fir-at ......... ....... X::� .......................... ..... Date Issued is Lastl, ...... .......... ........ . ......................... Other! , .............................. ............. ............... V- oi Showeraiii, ...... .......... ❑ "' round[] of wfter supply, hi. appllatl- AI "d find tha ;es noted, and find that the#p ,z_xie14,' of the Town of tPatterson .......... ) ...... 11.io ............. f ................. ............. r 4";