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HomeMy WebLinkAbout2058DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 36.48 -1 -36 BOX 18 02058 lkQ JrW I` r 1 i ., �. � 02058 SITE LOCATION 193 FA t MAILING ADDRESS OP PUTNAM COUNTY HEALTH DEPARTMENT DIVISION OF ENVIRa*ff I 225 -0310 PROPOSAL FOR SEPPM DISPOSAL SYSTEM REPAIR _ PHONE 2- 7 - J-2- / TM# /- Z.o�. -21Z) PERSON INTERVIEWED l� Q i A, J n C� ®,�;ti v 2 1 � � �N � � PC HD Canplaint # Name & Relationship (i.e, bwneritehant, etc.) DATE -/0-2/ TYPE FACILITY I rol ,,., f2 e Y PROPOSID iNsTALLER. i t A,1 0 C' ter✓ y PHONE 2 Z 7-7 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. Iv Qcmoti k PK1 s 4;.,'c, mel, ?L Yedi<- 10,4k A,ra 2rP1�c� w l�k l000 e,41— PCgs4; C iM J k .. A V0 ^rv-S 4.4 l 2 Le—xic e�. 4 s Iva close 4o ,a 4 is wg L s c, ��.2Srs Proposal approved V 's Sicftfature & 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. G' �l to 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 r rep/o�rted a ent of owner agree to the above conditions. SI.NATURE TITLE DATE -� ©� CKFS: Wiibe (POLO): Yellow (Tvn HI); Pink (AalicEint)