HomeMy WebLinkAbout1592DOCUMENT CONVERSION SERVICES PROVIDED BY
IMAGING & MICROFILM ACCESS, INC.
www.scanyourdocs.com
631- 589 -8100
34. -5 -42
BOX 15
1 rm
iA%
Ll
ri
r '
01592
PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
PROPOSAL FOR SBOM DISPOSAL SYSTEM REPAIR -73
PHONES ",,Z (-/6
SITE
TO 7�
MAILING ADDRESS
PERSON I VIEWED, PCHD Complaint #
G Name & Relationship (i.e, owner,tenant, etc.)
DATE IQ �`l C� TYPE FACILITY
PHONEs.5�'�.3
REGISTRATION # 1(23 -'IF
Pro (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.
Q D o .4/dk e,
Proposal approved
Inspector's Signature
Proposal Disapproved
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 camponents tied to two fixed points
d. System description (e.g., 1250 gal. concrete septic tank,
drywells surrounded by one foot + gravel).
e. Installer's name and number.
or A
=
(e.g. house corners).
three precast 6' diem. x 6' deep
3. System repair to be performed in accordance with the above proposal and conditions.
I, as owner,.or re t agent of owner agree to the above conditions. �^
SIGNATURE (° ;� • r ! TITI��`'d` -t DATE to
j
OPM: W-dte (PQFD); Yellow (Ttvin HI); Pink (APPUamt)
. ♦ 1
Uti
I
WIALU e, P!57 i
u, 4- + SoLI p A
Z 71
i 61
Ii N
n
i
i
'I
it I
I j t
i I
i
f�rX.7�a�lG
1
r
I!
'o
K/C L L
o
EVE
I
H
�
J
N
a
�
Uti
I
WIALU e, P!57 i
u, 4- + SoLI p A
Z 71
i 61
Ii N
n
i
i
'I
it I
I j t
i I
i
f�rX.7�a�lG
1
r
I!
'o
K/C L L
o
EVE
I
v+�
V..
7;,e
AS _BUILT" DATA.
Structure Ocaled from surv'oy by survoyar noted below®-
Well located b y: Surve y rs survo y. _ — _
wool dri lers roport
Englnelera mesurements ❑ — — _ __ _ — .
I
TCnK, cr,sab• pll*,gollortec 9 laterals located. by:Controcfnt:
• 1 E n0•wa�r.
. , Health Copt:
pls.l-3 inspection by: Health dppf® dote:_ r0_"SJ
En' (near data :_ - 4's
NOTES
,ir': E •_5¢ 7ir 91 a • -5� _or _, `� �I t
A a, - r? :•,_�1 kt ^-••- -
I
I
A 1`�:Rl S`ISTEM DESIGN "AS BUILT"
10VJNtli
_11-11C A7 /? -,:7 i/ , - 77-77-
LOCATION D'ite
n'Pa ! •�i.t:'7.7."�C �unIY f�G,/Ti�NState*
MOU (�Tiv %9
'1 c BI ncl. z I L UT N' ._ • ZZ .... ._
Sri U.♦r /r, C• ��• `_ `` -_ _. t._ ._ ..- --
-'>s•.1_calf. / / /cS,��IJob N�Q�
I I 11 .K Dw 0
�l : ► N N'• r k L • N T I S S F? E
��QtV:IIITtNG EhCtNElR
111 ` � I;Ah�ll I N1 ll`r,f), 19h ►I d7d•4! /l1
lP
v+�
V..
7;,e
AS _BUILT" DATA.
Structure Ocaled from surv'oy by survoyar noted below®-
Well located b y: Surve y rs survo y. _ — _
wool dri lers roport
Englnelera mesurements ❑ — — _ __ _ — .
I
TCnK, cr,sab• pll*,gollortec 9 laterals located. by:Controcfnt:
• 1 E n0•wa�r.
. , Health Copt:
pls.l-3 inspection by: Health dppf® dote:_ r0_"SJ
En' (near data :_ - 4's
NOTES
,ir': E •_5¢ 7ir 91 a • -5� _or _, `� �I t
A a, - r? :•,_�1 kt ^-••- -
I
I
A 1`�:Rl S`ISTEM DESIGN "AS BUILT"
10VJNtli
_11-11C A7 /? -,:7 i/ , - 77-77-
LOCATION D'ite
n'Pa ! •�i.t:'7.7."�C �unIY f�G,/Ti�NState*
MOU (�Tiv %9
'1 c BI ncl. z I L UT N' ._ • ZZ .... ._
Sri U.♦r /r, C• ��• `_ `` -_ _. t._ ._ ..- --
-'>s•.1_calf. / / /cS,��IJob N�Q�
I I 11 .K Dw 0
�l : ► N N'• r k L • N T I S S F? E
��QtV:IIITtNG EhCtNElR
111 ` � I;Ah�ll I N1 ll`r,f), 19h ►I d7d•4! /l1
I.
r
.•p .
J
I
1LL� G- otlo�,
v/�pl.L e11oS
3001 -0; `ra f
aVl
n �
4-�5o(ap pG 'Grp "4 c.
it
�o.v V- Ge
Well located by: Surveyors survey.—
Well drillers report -- F1 /
lD Engineers masuremants ❑ -- - -- - _
In Tar. k, boxes, pits, galleries B laterals located by :Contracinr.
N - -- - -- - - - -- Engineer: ❑
.. i - -- - - - -- - - - - -- -- '- - _
- Healtheapl: ❑
} - Pid.ld inspection' by: Health dept 1o�I dot a:_ 1Q_7_07_: - Engineer Ks _ dote
rutnam coil
Division of Euviz
owed as. notes
In
,� � • +DDlioable• Hules:
jI teamtnam �oyn*y HeHe:
V 1 Jl��rr/J
�`l,� .ttrmyttn•w • Ttt1
_
►h.,i ih. sa:v,r l•a ?a
_. di vl,•..:,i aai riS: Ka.: r, is: r Sri .:A :;�
NOTES: 44 ', �, l
inAi r.0 ,•dy'..-�
wi rLti +s-- IFIA,y�anda ! h:a i IW•
::vei via v., iu�l C: il•IiY`;�a,: L.•t.•,r �i;i
- c•m.i n,ri,.d in :;.., r.lanre viih ,il l „ °-. .i
i _ �r :m.!�,�A iulvv •d 'r•�gn l:.l ;un. ul F
I •:• ..- tLv I'.•.II. D. t. ;i;r �. 5'. S. U.II. �, J.t
j DI MENSIONS
oil
rA. - D - -SQT �/� 8 - D T Qq t,1 i r• i,
"!f '- E r1 4 B E
S
p _ _
A - K 7'-� - - B K -
SANI- TARP.._ SYSTEM DESIGN "AS BUILT'” '
-'
: - OWNLR:�'I_h147` /�: ''.•�/ / /�/ . U L -- — —
LOCATION Streat T d
Tovrn.�JT_j- .G,�?�,'/�•�Couniy: (1T�A/KState•
Dey , rtIDl�nt- of =Heslt - —: S U B DI-V _I.O N-• /•C7 ' - -
irtal Health Service,_ �%? -�<� ?
- - - Block. -- --_ .2 - .- LOT N+
for; gu
confox>asnoe with 13.0 13.0 ee r
ad helations_of the : _ - - — — - _ - -. - •- -
e t Surveyor: O_ /3LcJZT - - -= - • - - -- -:.. .
own - ��(Oate 6 =// B7 Scale: �U =So/ Job NO��' /•
JOHN H PR ENTISS PE DMo >
CONSULTING ENGINEER
RD ��, %.�••� i. ItAkME L NY 10512 —(9141 878 -6170.
.a
N!
�i
r
t�