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HomeMy WebLinkAbout1615DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 34.13 -1 -4 BOX 15 01615 6 ir r 0- I cf. , k4J6.j 01615 DEC -24 -2001 11:09 P.02 PTITNAM COUNTY HEALTH DEPARTMENT DIVISION OF ENVIRONMENTAL. HEALTH SERVICES • • / - FAI FAA OFFICIAL USE ONLY -® PERSON INTERVIEWED PCHD Complaint # Name & ReWfidnsbip Ue., owner, tenant, etc. DATE TYPE FACILITY • I/ Progg: ai (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 re uire submittal of proposal from licensed professional engineer or registered architect. k, 17 Y 3 - �� I, as o e;, or reported. g t .f owner agree to the co ditto s sta s form. SIC CAL! TITLE OQ C / Pm osal =roved with Jlhg followin& conditions: I. 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 comers). 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_' Inspector's Signature & Title COPIES: White (PCHD); Yellow (Town BC); Pink (applicant) PC -RP 99M L D TE DEC -24- 200111 :110 GO uNn' Job. Name Address City 99 Maple Grange Rd., Vernon, NJ 07462 Block I-800-420-6166 Home Phone # Job Description !—ryod" Statq*-�' Zip Lot Date fiblj—v 'dov A P.03 TOTAL P.03 7' Ll Ar V 711 F7 -J 09 .1 i —4— I t 7 00� 09 7— f ?7— TOTAL P.03 DEC-24-2001 11:09 o FAX Date Number of pages including cover sheet Phone Fax Phone CC. Fro P.01 ALL COUNTY RESOURCE MANAGEMENT BUILDING AND INSTALLATION DIVISION 99 MAPLE GRANGE RD VERNON,NJ 07462 Phone 800-428-6166 Fax Phone 973-764-6404 1 y - ' . „�” •{t 5'- v -.fix n 117 v .i b PUTNAM COUN HEALTH EPARTME C ®�� DIVISION OF ENVIRONMENTAL HEALTH SERVICES ' P>E2 ®P ®SAI, FOR SEWAGE I)ISP ®SAIL SYS7fEM kPAIR OFFICIAL USE ONLY SITE LOCATION 1 - 4 TM# o * ,,OWNERISINAI�E 4r C5 N N► ( - ' , t� ;3 MAILING ADDRESS i OAL4 r I Aty /or'/ PERSON INTERVIEWED �'YA PCHD Complaint # ame & Relationsinp i.e., owner, tenant, etc. , ._._DATE! a r•• va t :PRC)�I'OSE12IxNSTALLER (�)� [? I I �i �r -�n.1 j , �t NJ PHONE ADDRESS l , 1 L IIIEGISTRATION# i i xy E x. gT0�O :(fii6 udi sketch locatidg iH adjacent weflls)o N 4 1�0 Repair must be in same location and of same type as original sewage disposal "system .Different location �� { 'imyrrequire submittal of proposal from licensed professional engineer or registered architect. zlg .. .-, �:; i• i f is i p . I, as Qwmer; or reported agent of owner agree to the conditions "'stated oii this form: A£ i , ( SIGNATURE _ TITLEi� •DATE Proposal approved with the following conditions: 1 Procurerrient of any Town permit, if applicable. Submiss{Lon of as built repair sketch in duplicate showing a Owner's. name - + c r _- �.. b. Site Street Name, Town and Tax Map number. ; c.� Location of installed components tied to two fixed points (e.g.,house comers)' d. System description (e.g., 1250 gal. Concrete septic tank, three precast 6' diam. X 6' deep "l e. Installers' name and number. p 3. System repair to be performed in accordance with the above proposal and conditions. Proposal approved -� j Inspector's Signature & Title _ DA COPIES: White (PCHD); Yellow (Town BI); Pink (applicant) . PC -RP 99NII, PUTNAM COUNTY HEALTH DEPARTMENT DIVISION OF ENVIRONMENTAL HEALTH SERVICES PROPOSAL FOR SEWAGE DISPOSAL SYSTEM REPAIR OFFICIAL USE ONLY 1 SITE LOCATION 39-.13- 1-A TM# 37 ()C) 13 -� OWNER'S NAME! J AM66 AA) MoN ► (A L[AtYn i4 PHONE $4-425 J X3.3 MAILING PERSON INTERVIEWED mai i -LA 0tj PCHD Complaint # —Nwne & Kelationsnip I.e., owner, tenant, etc. DATE TYPE FACILITY PROPOSED INSTALLER ��W�I �5 �t�N`�T1;:�(7 i D1� PHONE 9 1J RR % ,Ro110 d f ADDRESS 31 - REGISTRATION# 7rhf 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. -. -1 I,.as.owner,-or-.revported agent of, ownei:agree to the. conditions. stated. on.thishrrri.,____: _ SIGNATURE�%�;L%�idti- TITLE DATE J� ^ 1 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 comers). 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 Inspector's Signature & Title COPIES: White (PCHD); Yellow (Town BI); Pink (applicant) PC -RP 99ML 11-2, ;�� �2- -- tl DA E �,.•� �� .�- (ham fN. �A f i i' i , d 5 41 3c `I 3Lt. 13- i —Y