HomeMy WebLinkAbout2012DOCUMENT CONVERSION SERVICES PROVIDED BY
IMAGING & MICROFILM ACCESS, INC.
www.scanyourdocs.com
631- 589 -8100
36.39 -1 -20
BOX 18
02012
11
.
Ir
r
'
'
1j
0,6
+
i
r
r�
I
'
`
1
02012
}
PUI'NAM COUN'T'Y HEALTH DEPARTMENT
DIVISION OF ENVIRONMENIAL HEALTH SERVICES
...., .__. _.. -225- -0330
�.�..._� ..,. , a
PROPOSAL FOR SEWAGE DISPOSAL SYSTEM REPAIR � � LD
OWNER'S NAME 1�a \rG3 I (.. FP ' N e. V 1 i PHONE _Z2 tf - qq 7_J
SITE LOCATION TO
MAILING ADDRESSF}
PERSON INTERVIEWED PCHD Canplaint #
Name & Relationship (i.e, owner,tenant, etc.)
DATE TYPE FACILITY
L' _ ► •
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
s signature &
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 canponents tied to two fixed points
d. System description (e.g., 1250 gal. concrete septic tank,
drywells surrounded by one foot + gravel) .
e. Installer's name and number.
Da
(e.g. house corners).
three precast 6' diem. x 6' deep
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
PIES: %bite (FAD): YeUc w (T nn ET); Pink (App 1amt)
OR i J
a
Proposal approved
s signature &
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 canponents tied to two fixed points
d. System description (e.g., 1250 gal. concrete septic tank,
drywells surrounded by one foot + gravel) .
e. Installer's name and number.
Da
(e.g. house corners).
three precast 6' diem. x 6' deep
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
PIES: %bite (FAD): YeUc w (T nn ET); Pink (App 1amt)