HomeMy WebLinkAbout1225DOCUMENT CONVERSION SERVICES PROVIDED BY
IMAGING & MICROFILM ACCESS, INC.
www.scanyourdocs.com
631- 589 -8100
25.63 -232
BOX 12
I No
oil
�}Ll.,
L
-
1
,
.
�
.
r,
L '.
Ll
01225
�}Ll.,
L
L'
Ll
01225
PUTNAM COUiY HEALTH DEPARTMENT
DIVISION OF ENVAONMENTAL HEALTH SERVICES
P-w
PROPOSAL FOR SEWAGI&MOSAL SYSTEM REPAIR
YES N Inteinal Use Only,. -
❑ Repair Permit issued in last 5 years ❑ Not in Watershed
❑ Repair within Boycrs Comers, w. Branch or Groton Fags Res. 200ODelegated
El Repair within 200 ft. of a wateroourse or DEC - mapped ❑ . Joint Review {
—75 SITE LOCATION TM #
OWNER'S NAME ROna. /d 1— GtGd,S PHONE # 279 ;,.Z6 � 3 .
MAILING ADDRESS Pa fjer, 561-1 , Al Y
APPLICANT1
Name & R adon�ownr, tenant, contractor)
DATE Ie la 6 7 FACILITY TYPE {CGS. PCHD COMPLAINT #
PROPOSED INSTALLER �G���c� J'��7 /G` 7y -�' PHONE # ,27?—ffd f
ADDRESS (/ &Z,1 EGISTRATION /LICENSE #
Proposal (Include a separate sketch locating the house, property lines, all adjacent wells within 200
feet of repair and the location of existing and proposed trenches)
NOTE: Repair must be in same location and of same type as original sewage disposal system.
Different location and proposed pump systems will require submittal of proposal from licensed professional
engineer or registered architect.
I, as owner, or reported agent of owner agree to the conditions stated on this form
SIGNATURE TITLE � !-z
Proposal approved with the foi owing conditions:
1. Procurement of any Town Permit, if applicable.
2. Submission of as built repair sketch in duplicate showing:
a. Ownees name
b. Site Street Name, Town and tax Map number
c. Location of installed components tied to two fixed points
d. System description (e.g., 1250 gal. Concrete septic tank, etc.)
e. Installers' name and phone number
3. System repair to be performed in accordance with the
above proposal and conditio .
Proposal Approved Proposal Denied
Inspector's Signature & Title Date
COPIES: White (PCHD); Yellow (Town 81); Pink (installer), Orange (Applicant)
PC -RP 99ML
c'
DATE 41W1 7
C&MI
A
I
fi
'1
m