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HomeMy WebLinkAbout2056DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 36.48 -1 -34 BOX 18 02056 11 PUTNAM COUNTY HEALTH DEPARTMENT DIVISION OF ENVIRONMENTAL HEALTH SERVICES -6 t 3 Ll z f ` OALM' S NAM /�/ I V ` v k -� M(7 11 • �i © Li q PHONE 7 SITE LOCATION J �4 5 Y �''i Y1b J� TO MAILI ADDRESS AZ V % O E2 NG PERSON INTERVIEKW PCHD Cavlaint # Name & Relationship (i.e, owner,tenant, etc.) DATE TYPE FACILITY PROPOSED INSTALLER , f 4 G, Q C !- h? e 4a a 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. Proposal Disapproved Inspector's Signature & Title romsal amroved with the followinct 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 d. System description (e.g., 1250 gal. concrete septic tank, drywells surrounded by one foot + gravel). e. Installer's name and number. Da (e.g.,house corners). three precast 6' diam. x 6' deep 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 .. 1E1c: K'iibe (POD); Yellow Mytin 81); Pink (k#iamt) PUTNAM COUNTY HEALTH DEPARTMENT DIVISION OF ENVIRONMENTAL HEALTH SERVICES -0 PROPOSAL FOR SEWAGE DISPOSAL OFFICIAL USE ONLY �a(P 0 SITE LOCATION J - JAS P t-- P— QA, T-a ®AJ TM# OWNER'S N PHONE -9 L/5_- 27 f q� MAILING ADDRESS PERSON INTERVIEWED PCHD Complaint # ,/y� Name & R-eTa—tionship Le: -owner tenant, etc. DATE TYPE FACILITY PROPOSED INSTALLER *aJ -.5T AT e: ® F Al V PHONE fg-VS -- 2-7F- -7-S-65-- ADDRESS ? 0. ley, 5-Iq 2: a "(. 3r&AL AV REGISTRATION# J0,1 4- Proposal (include sketch locating all adjacent wells): NOTE;_ Repair_ must bedn same location and of same type•as original_ sewag�-cltsposa_l 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 C� /d'z� (� 1)4ty`�5 TITLE I-It _& e, + --` DATE / �• 1�-4003 _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 comers). 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 performed in accordance with the above proposal ani conditions. Proposal approved Inspector's Signature & Title COPIES: White (PCHD); Yellow (Town BI); Pink (applicant) PC -RP 99NE D® TE