HomeMy WebLinkAbout2018PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
POPOAI. FOREWAE DI SPdSAi.�SYS'T1gN[ AIR -
�FFICIAL USE ONLY
0-
SITE LOCATION �� t i 1 t W44A, C( k '� TM# 013
OWNER'S NAME PHONE 9 /y) 2 1;12 - sy��
MAILING ADDRESS -
PERSON INTERVIEWED 4 11,,,,.., /'�%�� /''� f PCHD Complaint #
Name & Relationship i.e., owner, tenant, etc.
DATE `/ 1��o / TYPE FACILITY
PROPOSED INSTALLER HEe� n Co ns �- �t )? C PHONE g' ys- _ Fr'
ADDRESS Z y G Q -y C ItS h o rl4 W Ad, _REGISTRATION# 3.3
Proposal (include sketch locating all adjacent wells): Q ti C) P-G_�
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,
as owner; or reported agent of owner agree to the conditions stated -on this -form.
SIGNATURE � '/: TITLE
Proposal ap=ved 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
DATE i�7�4/
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
e. Installers' name and number.
3. System repair to be perf9rmed in accordance with the above proposal and conditions.
Proposalapproved
Inspector's Signature & Title
COPIES: White (PCHD); Yellow (Town BI); Pink (applicant)
PC -RP 9%E
DATE
w
,r
HEK A CQNST., INC.
2'''6 Buckshollow Road
MAHOPAC, NEW YORK 10541 ;
I J CSI l:v / 845 - (nab -sob
33