HomeMy WebLinkAbout2045DOCUMENT CONVERSION SERVICES PROVIDED BY
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631- 589 -8100
36.41 -1 -28
BOX 18
02045
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02045
OWNER' S NAME R o b
SITE LOCATION
MAILING ADDRESS
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PUrNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENM HEALTH SERVICES
225 -0310 - - --•- azz . =aT_. .._�fy...�.....,_.: ,
PROPOSAL FOR SEWAGE DISPOSAL SYSTEM REPAIR
PHONE 2-79 —9,69?—
TO 27 =4 -1
PERSON INTERVIEWED PCHD Canplaint #
Name & Relationship (i.e, owner,tenant, etc.)
DATE TYPE FACILITY
PROPOSED INSTALLER ze rl PHONE 2,79'-9692---
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.
0
Proposal
tions:
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' diem. x 6' deep
drywells surrounded by one foot + gravel).
e. Installer's name and number.
3. System repair to be perfomed in accordance with the above proposal and conditions.
I, as owner, or reported agent of owner agree to the above conditions.
SIGNATURE
.. : White (PCID): Yellow (Tvn E'U; Pink (Anliaent)
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