HomeMy WebLinkAbout4836AUG -23 -2002 12:09 FROM MR. ROOTER PLUMBING TO .2787921 P.01
517E LOCATION
OWNER'S N,AN
PUTNAM COUNTY HEALTH DEPARTMENT
DMSION OF ENVIRONMENTAL HEALTH SERVICES
� 01"W"W" I pill
MAMING ADDRESS
PERSON W ERVIEWED PCHD Complaint #
j r Name & ReWiNV4 ll.e., owner, tenant, etc.
DATE 'TYPE FACUrY_ %� J_be_%'n1r'% fir L
PROPOSED INSTALLER ,_; oo ESL
b- ba(o
PHONE 1-Y.
', (o M4_t Z-J 0_-
ADDREsAO &Y I AO P(L* r &r1JP4
ccey MI
REGISTRATION#
t.liJtitJ(,
pz= (include sketch locating all adjacent wells):
NOTE: Repair must be in same location and of same type as original sewage disposal system .Different location
pq require submittal of proposal from licensed professional engineer or registered architect. .
12-
I, as owner, r Trtedd a*& of owner agree to the conditions stated on this fomx.
SIGNATURE 1TTLE DA TE 6 Z.
Proflosal atroroved with the folio 'nQ 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 corners).
d. System description (e.g., 1250 gal. Concrete septic tank, three precast 6 diem. X 6' deep
C. Installers' name and number.
3. System repair to be performed in accordance with the above proposal and conditions.
Proposal approved.
9___ .
Wpector's Signature & Title
COPIES: White (PCHD); Yellow (Town BI); Pt* (applic at)
PC -RP "ML
Tf1TlN O (24
OF P. 1