HomeMy WebLinkAbout2027DOCUMENT CONVERSION SERVICES PROVIDED BY
IMAGING & MICROFILM ACCESS, INC.
www.scanyourdocs.com
631- 589 -8100
36.40 -1 -23
BOX 18
02027
17-200''
ir
go
r
-
r
�
T
M
P
02027
PUTNAM COUN'T'Y HEALTH DEPAR'II90T
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
PROPOSAL FOR SEWAGE DISPOSAL - SYSTEM REPAIR
OWNER'S NAME C7J��ca - r 7�%a'�. � � i� f ., �� � to r: r
SITE LOCATION s27iti ertc h e-rrz,
TO
;?7ig - 0c�'�'o
MAILING ADDRESS
PERSON INTERVIMM PCHD Camplaint #
Name & Relationship (i.e, owner,tenant, etc.)
DATE TYPE FACILITY lylrx, -�2
PROPOSED INSTALLER PHONE 2 %�
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.
Proposal a Proposal Disapproved
Inspector's Signature & Title
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 (e.g.,house corners).
d. System description (e.g., 1250 gal. concrete septic tank, three precast 6' dim. 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
PAS: Mite (ECHM; YeUcw (TiAn HO; Pink (Appliamt)
I
1 �
� G
Ch
�Cf9-B�ju�► o�
G
rNW .e-
' •ki /O � �D�►t f/L -OJT