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HomeMy WebLinkAbout2078DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 36.49 -1 -15 BOX 18 J r- Z ;r 02078 ff- PUTNAM COUNTY HEALTH DEPARTMENT DIVISION OF ENVIRONMENTAL HEALTH SERVICES PROPOSAL FOR SEWAGE DISPOSAL SYSTEM REPAIR OFFICIAL USE ONLY 3 -7 S "- SITE LOCATION TM# -3 6 `f% -/-/A' OWNER'S NAME Z2,1b t-17iff �, F/� � t' %rib c -�" PHONE t�' S = 2 �e-I'S T MAILING ADDRESS 2 7 Ly 2 6-'d -1A4 ) 4 %3R Jy-,Ii �`� N Y /0�yy PERSON INTERVIEWED ad/-O-jr oN�r,� c�c «i G2 PCHD Complaint # Name & Relationstilp i.e., owner, tenant, etc. DATE / / - / L z-o 0 PROPOSED INSTALLER ADDRESS TYPE FACILITY I' . • ►! 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. Lt �vrc� S e r P -' 7 S i k 2J 1 Y r �� M I V1 !tit I T +-ve "JC `% i d N D (. (l`( _ L 14 S-Vey (1 An6&- V K �✓° �.v Qe �'G . : �`.. 11._ t w� i Vt t: Vt 5 � 0¢ ;f.� A re Pte..✓ I, as owner, or reported agent of owner agree to the conditions stated on this form. 4 SIGNATURE ,f� TITLE '1`'4t -1i1W A ff'-rcbDATE 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 and conditions. Proposal approved_ Inspector's Signature & Title A COPIES: White (PCHD); Yellow (Town BI); Pink (applicant) PC -RP 99ML ac Z99 z. IL 958 IL IL Z� MCK IL 24.77' Q 198 L59 17.61 ' 17.51' Z68 loo,(DO, 659 K 42.48 -- K 959 0619 Gilo 6L9 669 "CRI 6+-G tr6.G 94G T'0,99 qN. ac Z99 z. 958 IL IL Z� MCK 24.77' Q 198 L59 17.61 ' 17.51' 659 K 42.48 -- K 959 6L9 669 "CRI 4rG9 tr6.G 94G T'0,99 qN. 100.00' IL W 100.00' 49� 559 ac Z99 958 MCK 24.77' Q 198 L59 17.61 ' 17.51' 659 K 42.48 -- K 959 6L9 669 "CRI 94G T'0,99 100.00' IL 0 ac 1, d SITE LOCATION OWNER'S NAME MAILING ADDRESS PUTNAM COUNTY HEALTH DEPARTMENT DIVISION OF ENVIRONMENTAL HEALTH SERVICES 4_ - PROPOSAL FOR SEWAGE DISPOSAL SYSTEM REPAIR` OFFICIAL USE ONLY PERSON INTERVIEWED TM# �1 1-7 40 'F otec.-Pfim )Dg V (5 �/lJ PHONE �j _ z4QiV PCHD Complaint # DATE TYPE FACILITY, PROPOSED INSTALLER �J 6 64,4- e /,Q , PHONE 20 ADDRESS �13 ­7/id IV W1 REGISTRATION# 7,16 ZY0 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 from licensed professional engineer or registered architect. conditions stated on.this form.. _. ITLE DATE 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 and conditions. Proposal approved_ Inspector's Signature & Title DATE COPIES: White (PCHD); Yellow (Town BI); Pink (applicant) PC -RP 99ML WE I OUJAAF4 Z7 5 6404AM A),Y- ZOO � q 7 TO t, b•r-44 36 ?lee ji, , " 41, tz Jf�