HomeMy WebLinkAbout2394DOCUMENT CONVERSION SERVICES PROVIDED BY
IMAGING & MICROFILM ACCESS, INC.
www.scanyourdocs.com
631- 589 -8100
42.3 -13
BOX 21
%L !ELI -�
or
m L'
'`
1
I. I
rok
I II , I i
t it m ,
02394
OWNER'S NAME
SITE LOCATION `-j
MAILING ADDRESS
PERSON DdERVIBM
N
DATE
• I
PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF M-WROIeWITAL HEALTH SMWICES
I
PROPOSAL FOR SROM DISPOSAL SYSTEM REPAIR
WE
4 ay9 -/S-
PHCNE
7M#
PAID Complaint #
& Relationship (i.e, owner,tenant, etc.)
i TYPE FACILITY �� S
PWPOSED INSTALLER �c4� �;X� . -�y 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
ronosal approved with the following conditions:
1. Procurement of any Town permit, if applicable. 1
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
d. System description (e.g., 1250 gal. concrete septic tank,
drywells surrounded by one foot + gravel).
(e.g.,house corners).
three precast 6' diam. x 6' deep
e. Installer's name land number.
3. System repair to be performed in accordance with the above proposal and conditions.
I, as owner, or reported agent -of— agree to the above con4tions.
SIGNATURE TITLE u. DATE
IP1
C: *Ate MD); YeU w (� HL); Pink (Applicant) �
i