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HomeMy WebLinkAbout2029DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 36.40 -1 -28 BOX 18 02029 I� ` , I , LLJ �,,, ' T a. `♦ ., . J .� - .. rL. �,. � - IN 02029 PUTNAM COUNTY HEALTH .E• • ► ►E PROPOSAL DIVISION OF ENVIRONMENTAL HEALTH SERVICES •• SEWAGE DISPOSAL - X►..I. SITE LOCATION MAILING ADDRESS. PERSON INTERVIEWED DATE PHONE _ S! ?<' cor /L /Z-60 , AU",, it6 z TO /G? PCHD Camplaint # Name & Relationship (i.e, owner,tenant, etc.) TYPE FACILITY PHONE A7f - 6'a65 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 fran licensed professional engineer or registered architect. - is ,. L. s '� Z l K%4.._ Proposal approved 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. Da 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' diem. 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. L SIGNATURE C TITLE DATE • ` / CPM: Ghite (PQHD): YeUcw (fin HE); Pink (Applicant) T_LLp LOT 1258 Fd N360 25'30" W 100.00' Fd. sue. PARKING (BIT) u°� LOT 1259 E N CLOSED P S.W. (CO NC ORCH ��� WE LL O raj LOT 1260 O O ENCLOSED 2 STY. FR. ENCLOSED _ PORCH DWG. DECK m LOT 1253 3� LOT 1261 c 0 r0 X. S.W(BIT) ' (� Y/ LOT 1262 W 3 0o U �, • � ..... o -�-- .23 ! AC. _ 0 o -j L0 Z 7`� ors LOT 1263 L p Fd. S36 025'30 "E 100.00' left CMP \ :r Y: . SPOREHAf OR /VE (5' B/T J