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HomeMy WebLinkAbout1933DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 36.23 -1 -53 BOX 17 01Y I 4 LL �, r •, :I"; Mal a �L I' 'a all :r kP ' I I ■ 01933 PUTNAM COUNTY HEALTH DEPARTMENT DIVISION OF ENVIRONMENTAL HEALTH SERVICES - PAUPOS.AL FOR SEWAGE DISPOSAL SYSTEM REPAIR z SITE LOCATION OWNER'S NAME__ MAILING ADDRESS OFFICIAL USE ONLY (g�� TM# 3 (o. a 3 —1-6-73 PHONE 8'yr = �27�- %©v;Ll PERSON INTERVIEWED 0,,,e- PCHD Complaint # ame Relationship (i.e., owner, tenant, etc. DATE t��'b 1 TYPE FACILITY PROPOSED INSTALLER Sines &erg jn�,U &f. PHONE ADDRESS TRATION# e- Co & 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 requiiyre. submittal of prroposal from /licensed professional e-n/g�ineer or registered architect. n 4 Jv"- I as owner or orted a ent f. owner agree to the con- itioms SIGNATURE TITLE -DATE r a l I�Zrproye-d with the following 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 performed in accordance with the above proposal and conditions. Proposal approved o Inspector's Signature & Title A COPIES: White (PCHD); Yellow (Town BI); Pink (applicant) l24cli'I'P10