HomeMy WebLinkAbout2500DOCUMENT CONVERSION SERVICES PROVIDED BY
IMAGING & MICROFILM ACCESS, INC.
www.scanyourdocs.com
631- 589 -8100
51.14 -1 -12
BOX 22
TI
:;.,Lou L
so
I I f .I 61
T:
02500
OWNER'S.NAME
SITE IMTION
MAILING ADDRESS Rc
PUTNAM COUNTY HEALTH DEPARTMENT'
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
225 -0310 I 1 .
s?CE - DiSi- ^OHA_L �"3ST� s • REPAM . ! - ...... .
S R,3 G PHONE
TK
1_ n er i my Aroma A'
PERSON INTERVIEWED, KoGzf- mg1W PCHD Canplaint #
r Name & Relationshi (L e, coer,tenant, etc.)
DATE u TYPE FACILITY,-
'�`P�oPOSEV nasTALLER � l G DY PHONE 73q•-
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.
N A -o(N K w`► �t
':A C* 10 � --G4'� ► c� �
Proposal approved Proposal Disapproved
Inspector's Signaturff & Title te.
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 cavonents tied to two fixed points (e.g.,house corners),
d. System description (e.g., 1250 gal. concrete septic tank, three precast 6' diam. 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, or reported a engntt o_ frowner agree to the above conditions.
SI TITLE Curoz4A mm [0-
nMS: %bite (P D); YeUcw ('I3An HI) • Pink (k#ia3nt)