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HomeMy WebLinkAbout2025DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 36.40 -1 -17 BOX 18 -. , ., IN Ir �. 16 IN } ., 14 I N-6 ti IN 16 iricr m '11' -W Is 't &* 02025 I t" t t OWNER'S NAME SITE LOCATIOr PUTNAM COUNTY HEALTH DEPARTMENT DIVISION OF ENVIRONMENTAL HEALTH SERVICES PROPOSAL FOR SEWAGE DISPOSAL SYSTEM REPAIR PHONE 9 /Y- x-79 - 3371 ,jm# 3 6 . go _` - ,I -2� MAILING ADDRESS ©n z Plmyfc, Rre-,..sf' - PERSON INTERVIEWED PCHD Complaint # : Name & Relationship (i.e, owner,tenant, etc.) DATE 96 TYPE FACILITY 4"1 C. PROPOSED INSTALLER Mme. �1r IrQrL PHONE REGISTRATIOi1 # �C.. 1°31 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. PrIp 0SS over Ole- ,.e T Esc /Ae- Y � � ���o � � l T � k _ ��� �P s;r :�,�. I�zszlt" /?•T' .Ss 3 �� �� 6� K / a// CIA S 6'y ,3zlm,� �,izr Elves. /f> le Proposal approved Proposal Disapproved Inspector's Signature & Title Date 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 LYW lOPt6: Wiite (FAD); Yellow (Tai BI); Pink (APPUCant) TITLE ,�,sfl /�. DATE /d -,)-? -�G. IA Yom. ,' b ... �� � Q � � �, rG� � a Q �. � Gt �_Q�� �� � �. .� � _ .� I 9 PU TNNAM COUNTY HEALTH DEPARTMENT DIVISION OF ENVIR0NME3RM HEALTH SERVICES OWNER'S NAME 116" l 0 A 4a iA SITE LOCATION MAILING ADDRESS �� Ki SIB ,0,P I o6 PHONE Z 7 i- 3 3 7/ 7M# PERSON INTERVIEWED I PCB Ccmplaint # Name & Relationship (i.e, owner,tenant, etc.) DATE �z 4 --.1 TYPE FACILITY PROPOSED // INSTALLER %1 t= 4 � J ,�C -�'� `�r✓�� � - � � 7 PHONE REGISTRATION # 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. L�d� / /)L'l:. S s� C-/ 1 �c'�n �� c�� �C1i� //C 74A r, <f Jwzl fefA,,e r J 17y6 Aqe Proposal approved Proposal Disapproved s Signature & ue 'roposal 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 I)r000sal and condi ions I, as owner, o repo a t of owner agree to the above conditions. SIGNATURE ,,--t TITLE . ❑A C Aicl ?M: 4tdte (ECED); Yellrw (Tam BI); Fink O pliaant) pw ScPt�c"t'�+ti1��6- V.3cc! z ;r s .r 4� S A l CI �T�A �..' V� a 1 S: ' A'rJ4 a