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HomeMy WebLinkAbout1320DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 25.73 -130 BOX 12 l W.: �11r b' PUTNAM COUNTY HEALTH DEPARTMENT DIVISION OF ENVIRONMENTAL HEALTH SERVICES 225 -0310 ..PROPOSAL FOR SE KAM DISPOSAL SYSTEM REPAIR OWNER I S NAME ��� LrZ [-� PHCNE %Q yt- SITE IACATION J (14 ©/w) MAILING ADDRESS t� PERSON INTERVIEWED PCHD CaTlaint # Name & Relationship (Le, owner,tenant, etc.) DATE TYPE FACILITY PROPOSED INSTALLER ��� ��� PHONE � - 600, 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. i !41 ff—ZA M Proposal approved _ Proposal Disapproved Da roposal 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 corners). d. System description (e.g., 1250 gal. concrete septic tank, three precast 6' diam. x 6' deep drywells surrounded by one foot + gravel). e. Installer's name and number. 3. System repair to be performed in accordance with the above proposal and conditions. I, as owner, or reported a ent of owner agree to the above conditions. SIGNATURE A TITLE DATE OPIM: Vbitie (PCHD) t Yellow (Tam EI); Pink (AnliGent) (11 C. AC 6A) 6 Ll1:7 Ae A 4�c f'- J4 CK. 2-7 9 - 7 39 ?-- JOSEPH'HEFELE 346 LAKESHORE DR. PATTERS-ON, N.Y. 12563 R-244-92 7-23-92 ti INSTALLED BY: i 41n • OV/ B.OTTGE SEPTIC, INC SODOM RD. BREWSTER, N.Y. 10509