HomeMy WebLinkAbout1621DOCUMENT CONVERSION SERVICES PROVIDED BY
IMAGING & MICROFILM ACCESS, INC.
www.scanyourdocs.com
631- 589 -8100
34.13 -1 -10
BOX 15
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SITE IMATION
MAILING ADDRESS �� �t J
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Name &
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TO
Pam Camplaint #
owner,tenant, etc.)
TYPE FACILITY
PHONE S6 � 7• 1 �r6r
,Pro (include sketch locating all adjacent wells):
:VOTE: -- Repair must be in same'location and of same type as original sewage disposal system.
Different location may require submittal of proposal from licensed professionat engineer or
registered architect.
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Proposal approved- G— Proposal Disapproved
Inspector's Signature & Title pite
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
drywells surrounded by one foot + gravel).
e. Installer's name and number.
3. System repair to be performed in accordance wth`the above proposal and conditions.
I, as owner, or reported agent of owner agree to the above conditions.
SIGNATURE TITLE s DATE [� y
PM: Write (PC:D); Yellow (Mm ffi); Pink (Anlicm t)
F
Bi-State, Inc.
Septic Tank Service
—Stair Ridge'R oad- --
BREWSTER, NY 10509
(914) 278-7565 (203) 746-0175
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OWNER'S NAME.
SITE LOCATION
PUTNAM COUN'T'Y HEALTH DEPARTMENT
DIVISION OF
. . _ ._ ....
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225 -31+0 r.. u�.
PROPOSAL FOR SEDGE DISPOSAL SYSTEM REPAIR
MAILING ADDRESS -rrt. Sq-
PERSON INTERVIEWED -'SJ
Name & Re
oz
U. e, owner
GI
PHONE
TO
S c es
7° - 7S
e
c Pal) Canplaint #
an ,etc.)
TYPE FACILITY
PHONE i p - S
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.
f ofL S 1
�W
NW 01117"=3
�J 2, ST.
Proposal approved
Inspector's SignAure & Title
Proposal Disapproved
with the following conditions:
1. Procurement of any Town permit, if applicable.
2. Submisgion 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 ag er agree to the above conditions.
SIGNATURE TITLE
I LPG: White (MD); YeUcw (fin ED; Pirk (Applicant)