HomeMy WebLinkAbout1378DOCUMENT CONVERSION SERVICES PROVIDED BY
IMAGING & MICROFILM ACCESS, INC.
www.scanyourdocs.com
631- 589 -8100
25.79 -1 -67
BOX 13
01378
IN
6 or
rl6
VJ6
�: .
.1
!
1�
I
r-164.
III :
01378
PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
PROPOSAL FOR SEWAGE DISPOSAL SYSTEM REPAIR
OFFICIAL USE ONLY
SITE LOCATION P n TM#
OWNER'S NAME Q4a Pr ` PHONE g2l-
MAILING ADDRESS
PERSON INTERVIEWED PCHD Complaint #
Name & Relationship i.e., owner, tenant, etc.
DATE TYPE FACILITY
PROPOSED INSTALLER, rtd��r perr `>�,,(% ,, A1, ��� PHONE_ 3 -.y,6 .
ADDRESS -?L/ Oi iZL A-,:� Ak' REGISTRATION #� 6"-' 0
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 liceAsed professional engineer or registered architect.
I,. as owner,' po a ent of owner agree to the conditions stated on this form.. -
SIGNA TITLE( �,g DATE C�
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 corners).
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_ L
."� a
Inspector's Signature & Title DATE
COPIES: White (PCHD); Yellow (Town BI); Pink (applicant)
PC -RP 99NE