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HomeMy WebLinkAbout2311DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 41.10 -2 -17 BOX 20 N '� ' .� L' . . . �oir4 f - r L . ♦, : , 02311 P" U a V -AU PUTNAM COUNTY HEALTH DEPARTMENT DIVISION OF ENVIRONMENTAL HEALTH SERVICES PROPOSAL FOR SEWAGE DISPOSAL SYSTEM REPAIR M OFFICIAL USE ONLY 6 . � 6 - o SITE LOCATION S- Z AC T &d TM# Y t 10 —2 1'7 OWNER'S NAME tl d c. Ht ck PHONE 9 Y 5- Y-Z k 9,00 (o MAILING ADDRESS y;, 7�t (/' i9 c c.EV l d S, PERSON INTERVIE`� ED J PCHD Complaint # Name Relationship Le., owner, tenant, etc. DATE � � � �v TYPE FACILITY G�,S PROPOSED,J%Il;jSTALLER x PHONE —o? S`� S- ou? 05G p4- ffA- R- � ADDRESS _ , _T � - - © "7 EGISTRATION# 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. I tzA.n 1#-C, iE GV-F/Z-v ,. -I; as owner -; or eported agort of 6wner -agree 4o ihe- 'conditions•s*.ated-,on - this- fortn. _.,.... _ ._ . ,_ SIGNATURE TTTLE/14�� DATE 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 �4— Inspector's Signature & Title COPIES: White (PCHD); Yellow (Town BI); Pink (applicant) PC -RP 99ML DATE