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HomeMy WebLinkAbout1659DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 34.17 -1 -5 BOX 15 01659 , 17%. QPJ �l I � I ' j 9 16 ;�t- r. ,' loin 01659 Iv i' PUTNAM COUNTY HEALTH DEPARTMENT DIVISION OF ENVIRONMENTAL HEALTH SERVICES p4r7. SITE LOCATION TM #_ OWNER'S NAME 0 Lln/ 0 LO MAILING ADDRESS q S3 i��rl r2- 1 LZ- OFFICIAL USE ONLY R - -1-3Y& / 7 PHONE 19- - 3 8 2 a Ny /os'/ti PERSON INTERVIEWED PCHD Complaint # Name Relationship (i.e., owner, tenant, etc. DATE G ^ 2 -- � TYPE FACILITY PROPOSED INSTALLER L­Q-)�_PHONE_Y_� (a ADDRESS '31 ©yeC i a `IC.,I. /Ia � L� � EGISTRATION# 'PC 7 f Pry (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. t � �, �.� DlCL[ k GtS p LCD �zr� -�-► L �,c I n� . 4-ew ,Ao lam "cztdyn . CaAl for, �?`.rk ' ,-o Y. 21 (6 1; as owner, "or reported ent of o, er gre 'to tine conditions'stated on this form. j SIGNATURE TITLE DATE 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 p rformed in accordance with the above proposal and conditions. Proposalapproved VJ _ % O Inspector's Signature & Title DATE COPIES: White (PCHD); Yellow (Town BI); Pink (applicant) PC -RP 99ML —V 47 04- 1,-,, V 'A .41 7 /(lD� ravd< Piet, i.cat,-e ©4(` leve ( &-fea- V) `ti Q Ayl 1. ta- .10