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HomeMy WebLinkAbout1916DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 36.23 -1 -2 BOX 17 01916 �' 6' ''- 1,10 A Ll r IT - L + I IN . MjI ' 'r - IN 01916 PUTNAM COUNTY HEALTH DEPAR1M4W fi 1 f l' ._... T � DIVISION OF ENVIRONMENTAL HEALTH SERVICES PROPOSAL FOR SEWAM DISPOSAL SYSTEM REPAIR` -�-- — SITE LXATIOr PHONE ?7 ? - t� TM# MAILING ADDRESS SyM� PERSON INTERVIEWED �',o%� � �, ,��y- ©Us'iu! PCFID Complaint # i Name & Relationship (i.e, owner tenant, etc.) DATE TYPE FACILITYZirne. PROPOSED INSTALLER me 6C1:;;-; f PHONE REGISTRATION # G f3/ 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. Proposal approved 11t l LJ 1 -1 till 15;11;i1-/. pz�is _ a' tya(1• Proposal Disapproved rkmtA 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 canponents tied to two fixed points (e.g.,house corners). d. System description (e.g., 1250 gal. concrete septic tank, three precast 6' diem. 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 g of owner agree to the above conditions. SIGNATURE -��, �-� _ TITLE j!�j C J ,AA?-te' DATE ZPI6: Unite (PQD): YeUcw Mai HI); Pink Qftlim t) PUTNAM:COUNTY DEPARTMENT OF HEALTH No.379- -19 COMPLAINT OR.SERVICE REQUEST RECORD PATTERSON DATE 5�6�96 REFERRED rTO TAKEN...,_ FM — - TELEPHONE CALL X IN PERSON LETTER CONFIDENTIAL 241 -0400 (w) REQUEST FROM Pamela Stipanovich TELEPHONE 278 -4508 ADDRESS 13 Batavia Road, Patte -^son ENVIRONMENTAL HEALTH:. Home Sewage Rodents Refuse Public Water Food Service Migrant Camp Other e O U) CCMPLAINT OR R VEST Septic running -onto- her - property from ranca; 4ire Road. Pa 10,114 %`'4 , o eta -?�w ACTION TAKEN BY c &,OZ4 a � DATE FINDINGS INSPECTION (s WE FINDINGS DATE FINDINGS PROBLEM ABATED DATE- .. PERSON �. ..tee.. ESTIMATED TOTAL MAN HOURS SPENT 77