Loading...
HomeMy WebLinkAbout1986DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyou rdocs.com 631- 589 -8100 36.31 -2 -19 BOX 18 .. . I 116 . J XI kQ 1 6 F r k. + N , , Ir R CC'S NAME SITE LOCATION MAILING ADDRESS PUTNAM COUNTY HEALTH DEPARTMENT DIVISION OF ENVIF014MM HEALTH SERVICES PROPOSAL FOR SEDGE DISPOSAL SYSTEM. REPAIR PHCNE 9 14- aI Z - 6 r- y TO pERSON INTERVI]7 D (` : ,, �o����— c'�wre� PC HD CCmplaint # Name Relat ship (i.e, owner,tenant, etc.) DATE S 9J— TYPE FACILITY h�,A e.. PROPOSED INSSTALLER c PHCNE v2- REGISTRATION # ,C, D/ 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. I l Groh �. fJbv© b r (`% I' e . 6��/. a, e- Owxtrs tea %n I— of X, Proposal approved Proposal Disapproved 's Signature & _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 corners). d. System description (e.g., 1250 gal. concrete septic tank, three precast 6' diam. 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 reported agent of owner agree to the above conditions. SIGNATURE ! TITLE DATE (FgB: %trite MD); YeUc w (fin HE); Pink (AF Ua3nt) ct nn¢�•��1F�� � � iil �' � Y JI xY }� {6�))ii �' t 2 V I t �j -' a + 1iti99 i 7"m 1 � ,>„�„r�y+re, i #E F .fi �, h f }. �•s� }� �� ��jE ,,�' ����(>d� r �r�.� -�l' ` I � � �i ��y�S�vlt,:� i�,f e � �', is' ! t 1 i fit' h`Y' r "sI• }S i �.4 I i v{ S � 4. 1,�''}'Ni .��� �>f�1tr+ `�'ki•�,f�'e, � {a E: :$ I, I ' ' t t - I t ��,, � _ r {u I ° F i. { J }its L r I' s k �ly r� �P aF..; t1j�r t� 9 r , [ °`tj i1 �y tT t�.a, i3��.W _ ro � I. _ E _ ...��•. /� I/ 1 b/(�' /, _ .. J _ .{ � I'.. , .. ! E . t • `4t : } f. ` t �<s Ijj�J,c �7 Y ���'1�1�� i} � i E .�-J ' ®a�/ �r✓M / GI�� C l0 ✓L'2� 1 _ , � I .. I ,I � � � � - ; iRF s � I I E J ! s '1'_a �'.Fu yr {'. yi�� + �s• � I �t In VCR. #-. ` r S ti i1 ` ty ! l "' , 2 ' y a� tai at I 1 �, E, •. I .. �. t \JS - 1 , � I -� ��• t t I. , i t tf'- ,� .' y' �.. .I, . • l , ' �3 t I A"� a. AX-1 Wei Bps a v\ INT1 ASK lot! •