HomeMy WebLinkAbout2510DOCUMENT CONVERSION SERVICES PROVIDED BY
IMAGING & MICROFILM ACCESS, INC.
www.scanyourdocs.com
631- 589 -8100
51.14 -1 -29
BOX 22
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02510
SITE
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MAILING ADDRESS M
PERSON INTERVIEWED Pa D .Complaint #
Name & Relationship (i.e, owner,tenant, etc.)
DATE TYPE FACILITY
PROPOSED A �1 8 13 Cn n 4-ra -b n R GO r Q PHONE 7/9-263-2412-
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
"*el'-
Proposal approved
s
-� 7W S rl WN
Proposal Disapproved
e-
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 canponents 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 agent of owner agree to the above conditions. /
SIGNA TITLE 0 y1 p_ r-
DATE
�FH S: Hhite (P HD); YeUc w (fin ffi); Pink (ki licant)
OWNER'S -NA 1g
SITE LOCATION
MAILING ADDRESS
PERSON INTERVIEWED
DATE
d
PUTNAM COUNTY HEALTH DEPART
q ' DIVISION OF ENVIRONMENTAL HEALTH SERVICES
225 -0310
PROF SAL' FOR SEVUZE DISPOSAL• SYS`ML kwrAI2
• i r
PCgID. Camplaint # p,
Nam &'Relationship (i.e, owner,tenant, etc.) �j
TYPE FACILITY Hn m e-
C, PHONE' -/S 9
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.
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..._:..� ..._O_..�.r� -� . !i!f- �^-` -e. _S�v�.�C..w�:,.c; �,/•�G-v -�.. _.i�PC;�_ ,C�%- 9��-�- G•a:.kr�f.�_, .
Proposal approved Proposal Disapproved
tonosal aunroved with the following conditions:
C
711,
V/1 l
Da
1. Procurement of any Town permit, if applicable.
2. Suhmission 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' diam. x 61 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 agent of owner agree to the above conditions.
SIGNATURE TITLE DATE
JU B: Mite (MD); YeUcw V 30 ffi); Pink (Anli0 mt)
A
•' ' . ` M
MAILING ADDRESS t1A M 6-
?ERSON INTERVIEWED PaiD Complaint #
Name & Relationship (i..e, owner,tenant, etc.)
)ATE 1/3,1 �St� -- TYPE FACILITY..
• •,• • •. �+� r •� a�• : R .• . • ._ +sue � � . • i `���`l���s
?r sal (include sketch locating all adjacent wells):
!IOrI'E: Repair must be in same location and of same type as original sewage disposal system.
)ifferent location may require submittal of proposal from licensed professional engineer or
registered architect. �E-AS-hv%� dryruedl•-f'o be.
��■ • r . c fir■ • • i
's
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
d. System description (e.g., 1250 gal. concrete septic tank,
drywells surrounded by one foot + gravel).
e. Installer's name and number.
(e.g.,house corners).
three precast 6' diam. x 6' deep
3. System repair to be performed in accordance with the above proposal and conditions.
I, as owner, or reported a t of owner agree to the above conditions.
SIG TITLE 0C.c) ✓I P- DATE / l�a O
PUS: V&te (P ED)s Yellrw (mn Ell); Pink Lk iau t)
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