Loading...
HomeMy WebLinkAbout1227DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 25.63 -2 -39 BOX 12 �. , Icy ~� T ;y kOi , I'� 1 ', L ` ' ` 1. I' rL IS i� No L 1r 1 16 kP r . T 01227 mum= .4s, "44 W.. T.A REAL TH :.-t PU' I NAM kUU1V'1 1. 0 ob-t 1-111 P•001 /001 F -508 ,.f.,..,DNAStQN,QF,.EWIRONMENTAL HEALTH SERVICES to - PROPOSAL FOR SM=1S005AL SYSTEM REPAIR NO Internal Use Only ❑ i . In la �%In Watemhed Repair PSI issued last W V Rapair WW�86yds Cmw, W. BWch W Crotr Falls Res. Del ted Repair vAR6 200 fL of a W'016rc=40 or DEC - mapped Wdarx! -Jointftview SITE LOCATION TM at I ; OWNERS NAME To+y) 0 LA PHONE MAILING AD DRESS lu— C LO 4= APPLICANT n -U Name & ftatkmsbiFf.e.. owner, tenant, cannaa) DATE FACILITY TYPE e PcHo comPLAINT # PROPOSEDIN VALLER LS PHONE# ADDRESS a REGISTRATION /LICENSE )q( .90 p_ rom§g (incliide a separate sketch locating the house, pmparty lines, all adjacent wefts within 200 feet of repair acid the ImtIon of 9XIsting and proposed trenches) NOTE., Repair most be in same fiocation'and of same type as original SMgO d!SP0SaI,$YsteM- .-Dift, peAllowtion and proposed-pump systerns will requirq submittal of proposal from licensed proftssionai engineer or registered 6roitii' n A-N A In A -+-.0 `i An ^,, ,-,u, as owner, or reported' ant owns ee e condificAs* stated on this form SIGNATURE TITLE •01,v c- r" i. Procurement of any Town PeWit, if applicable. Z , Subrwssbaof as Wit repair sketch in duplicate shovying; a. "Ownv?s name b. Site Street Name, Town and Tax Map number c. Loostion of Installed components bed to two faced points d. Systern description (e.g.. 1250 sal. Concrete sePtir., tank. etc.) 0. Installers' name and phone number 3. System repair be perfonro.d! to accordance with ft . mpoW and conditors. Proposal Ap f ovsd '',,.Proposal Den ied — -�Jizb&toes B-Ionature.& Ti Itle >;: k Di 627 DATE I A eA7 ld Ng 19-d4 1 11---* 0 0 *-j 5 r-4 L,FlD ADDIS H ab 3111 WIVJ 0 S v 0 30 11 oo; �,6 0 I C" cc 0 (no-taf) yd ID 01, O 6 BIRCH CON Sheet of PUTNAM COUNTY DEPARTMENT OF HEALTH -,D1-'%.-7IS10N.0FEN.V.-IRO ' NMENTAL.HEATLIT -SERVICES FIELD ACTIVITY REPORT WIFALVAI �.v C V ADDRESS:,�41-� ZA 9A-ag! - JZ5,0 AJ Street Town State Zip PERSON IN CHARGE WGIM-12% 11 MRATA I MAI ff§]NWj Name and Title TYPE • FACILITY:, WAY aW Its o. ve.,L, N A4Q 0 A O e94 76( z o of i Wj Signature and Title RFPn"RT,RF.CETvF.T) gy: I acknowledge receipt of this report: SIGNATURE: 02/96 Title: D — 0 0 . -I# ' cn Rome- Aq r f