HomeMy WebLinkAbout1919DOCUMENT CONVERSION SERVICES PROVIDED BY
IMAGING & MICROFILM ACCESS, INC.
www.scanyourdocs.com
631 - 589 -8100
36.23 -1 -9
BOX 17
,. - dmE , .
' l"LL. �'- .`, ..4
- I ■ IN
I ,` 1 d h-4 .
01919
OWNER'S NAME K�
SITE LOCATION it
MAILING ADDRESS
PERSON INTERVIEWED
DATE.
PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF.. ENVIRONMENTAb;- HEALTH, SERVICES,
PROPOSAL FOR SEWAGE DISPOSAL SYSTEM REPAIR
N �— (� 0 1- S PHONE
Tkoyx S c ni
QSo.•.! !Jy
ID
?9 /z7
it 0 Y�, A 2. PCHD Complaint #
une &Relationship (i.e, owner,tenant, etc.)
TYPE FACILITY I - (A, 3 Cc) .
t4d 660,-,W04- (26'y'-4 C-0 PHONE Z 2 T _r, Z'i -7
REGISTRATION # :7i-T
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.
V�c La S N t %��crS. � �1l S `� r•,Y- W t� �� [ S
C r IrAv,„x J�TF Ln S . Ak,�,) �c- Ltn s 1 ni .5A-,m Ae d
iyo C-Lo s go-P +n Aviv v-) q. (CS o ,e WA4,F,2 co vt a s c s
Proposal approved
s Siqnature &
Proposal Disapproved
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
d. Systan description (e.g., 1250 gal. concrete septic tank,
drywells surrounded by one foot + gravel).
e. Installer's name and number.
(e.g.,house corners).
three precast 6' &am. x 6' deep
3. System repair to be performed in accordance with the above proposal and oonditions.
I, as own or reported agent of owner agree to the above
J /conditions.
SIGNATURE TITLE �r 6, MM -Z,ze
. C: V to (PAD); Yellow (2n ED; Pink (Applicant)
.P.O. Box --;62--l-
CARMEL, NEW YORK 10512
(914) 225-6277
c� -7 1 —,I 07
Tkelm
t 4 t4-
Av 7�6
P.O. Box -62 -1
CARMEL, NEW YORK 10512
(914) 225.6277 Pe-
P, '71 -4 )12-/
rd
:2 - 1,. - 9. �'
q S",