HomeMy WebLinkAbout1896DOCUMENT CONVERSION SERVICES PROVIDED BY
IMAGING & MICROFILM ACCESS, INC.
www.scanyourdocs.com
631- 589 -8100
36.09 -1 -13
BOX 17
17-2 WX x';'
r . .
` *
' 1 r � k
�`ti. �
ir
, i
r -
PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
';t'1 lw w�v, -
SITE LOCATION V542 Z0,,-;,v, -A-ti r J
OWNER'S NAME (::�; CZ f E t- (Zi,:;'
MAILING ADDRESS 12/0 4r.rr -r5- 6��
OFFICIAL USE ONLY
VX
TM# 36.00 H3
4, ld 2c"s S cIPHONE a
PERSON INTERVIEWED N (A, PCHD Complaint #
ame & RelationshiD (i.e.. owner, tenant, etc.
DATE 5-- 6 - O
NIA
TYPE FACILITY k66 111 fl 14 L-
PROPOSED INSTALLER G✓ tw t 4" 6olr &C 60 ffT-) E SefTtLPHONE.
ADDRESS '5� s° 0-- � 2OA-0, g rL07^'sTr---I-- REGISTRATION#
279 - 6,069
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.
5r, C A- Mt -CWev -5 Ke'rC-4f. Grzv4t( � k.S*-A)oO-d EKcsnAolq 5eTrcC T_eWk,
A-sf>+vvoJ Oct SrNk Fco-o5 trJ Pt.A -cf, ' 1,0 5TnCc,, PVW 15-00 &A cum
`ierTL 7)�fwI< hw D 1—F ± 2' w 1 of A6 S T-jr, c-�ac_f f e5,
N e4 -tipsy weu5 ,4-ti,E f ftew.✓, /Z"A -t2 ,attic, mA-tniroTtAl loot ml v, Tv 4t- weds,
I, as owner, or reported agent of owner agree to the conditions stated on this form. / t
SIGNATURE TITLE�tM2 c, P ��C� l ti�"� DATE / L �T
Proposal Upproved 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
Inspector's Signature & Title DATE
COPIES: White (PCHD); Yellow (Town BI); Pink (applicant)
PC -RP 99ML
Q
0
z
i
t
1�OlG
r
?O
W l&,
'rks�rc►f Cr,'P)
CAI,
.f3'G57 •� '
�T
'eS
.P?�X
IV. OOr
111 •�°`a'd��v -i
, aV
MB"rnL-
�Y ^ 5 V.M
r - ROX(neATE
4 -�T1ON eF
Wsr,gb WBtL
J G•�c.6
PYC -S C„
2 : MIN.5t0RE
2 s-r eY Btu
0MIN. 1
�
u
�4
Cry
F Iz
SSTS K-EPAl p, �oR
I
507° YS'_ 36 "r.
{7q,gV'
Q
3
�Ro'FbsEU Y'
PYt: 31R 35 ca
27. MIN. SLOPE
PRoPQSED ISOD GAL
PkEcF&T contct�
SL -Ptic TANK
F- Kjzr/1JfI SSTS TO BE
TaDwca, PUMP, CRUSH,
�k DON ekiSTlNfr SePfiG
IN DACE. ON
GREEN C{+irWE�Y-S cH ILDRENS SCii6o,
3UIi.pIN f4 KNOWN AS THE
C LASS 401115E
'1119 90ANSBOK6 ROAD
-TOWN OF SovQeA&r
TAX MAP'&
MAY �, 2oay
BA°QMflP IS TAMA FRDM 45URVLY OP PRO>?ERTY 'PREPARtO Fort QinDe2iCI(t ROBIN
MAORnE PRePgReD BY Rp1DE1tT kk. 3ERbeNaoVfF, PrtteD
Insite Engineering, Surveying &
Landscape Architecture, P.C.
3 Garrett Place
Carmel, New York 10512