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HomeMy WebLinkAbout2563DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 52. -2 -2 BOX 22 02563 ., or i,yti , , r rr +, a . Low NJ Is NN — , �„ r. IN 02563 PUI'NAM COUNTY HEALTH DEPARTMENT DIVISION OF ENVIRONMENTAL HEALTH SERVICES 225 -0310 PRaP3SFcL' FOR 3t�E° D�5P05�AL`SY5T REPAY OWNER'S NAME Warren Moscow PHONE 529 -5386 SITE LOCATION- . �p r 011 � ;Ae�?o- 9�a� avimi- Vat le y MAILING ADDRESS same PERSON INTERVIMM PCHD Complaint # Name & Relationship (i.e, owner,tenant, etc.) DATE TYPE FACILITY Pro (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 fran licensed professional engineer or registered architect. ace attached ���► LJ Proposal approved Proposal Disapproved 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 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. SIGNATURE ..E : mite (Pav); Ydicw amn Eu; Pink onliaint) TITLE DATE r ,. r h _ .> _ - 1 _ G > _ i. F Sa 3 - -L 11 C. - :�P�,,, K Y Y. - ry Warrenosociw z _� : 11 - r ZV� = :, :. r t. . - _ ,t. E _ _ ., .. -. - _ AU Ust.2,Q�� , y .e�rt?ent n�eslth` T 'utnam Cunt ANY °_. 1. y� Gq► tleinen { 11 f �{ f �- �n �d us t ,:s3 We zi�tii'i�c7 �o�? . hit wa �uap ®rted w® '�tsd ._� -a ,a:--S-OP —c-, ta* k la�ka ®- n , u,,i �t n , r pros nt t�ve con rmsd •this,. Ra►th�ar t_rii wait fnr tha arri��l o °f the.= to ®rmit ��?�licst {_z+n, :F which dame todm, wo_proG�8dad to rsatifT th4 sitution� 11 Xast�rdwg; �v�iast lI, :w� h d the tin -k ,6 #I _`out .b� w" i �nwo .l of P40k$ki�.l, ;end Howicrd Uragert, 'uthom Mill, `s Cora Itrsatnr, : irrstal:iod' ;new L -250; ��llon -_ anv6 a tank sand 'don.' -ha 4 - it to Pia d ;iyin - Qwithin the air = ®� oP the ®ld P�1.d; .� .3 r s " nr Z ,� G�_ �, - _ re 10 se akatoh: ©.fl the work.. done _ ,.T �2r. - :r��ert. S sly y 11 .i, � Y -..' ik"` 4 fk ,� b t h.. _ y., `. 4 .. ' S . 1C £ F- F.. -r ky,� S y. T ,L`, ..S R . tT „ y }- v;' .- . p` - - x;,. ` _Y' Warrora:oscor , f,...ex ax r a-n.` s � ' y -" r S a6� - "�- F -fix - 11 I. ,> �, - ,- - ,:. .. #:.. ..3 - .� - w - .'F^ i -t C 1. w r - tl - - ` -. - - N - be .x. " It ,N T ��a., - 'G. ic.' -4i '. - P .q. F " 'K .1':i+C -c"§� �.eY+Y i -y S, :�q ¢� **ya -' d -� F Y 6 k d I -'e ��f - { , - ", - e _ - - - v -., .." - "z',a - _ - - . f ? fie i - 'p _ 4 4 - Y � i� J b 'Y T _ - - _ .r: qyam. mf :s +� a..�'.. . ¢..• .r` �"`-r� _ 1. i. ^- °2 a� 5L g' �'' r - - I rte 't- L. 4 - ^y w•` _t _ J i .�, - _ _ 3a as , z - 4.- - ,. . .. - - - 11 2, - _- �i , d D _'s' -' < w. b .+c. _ - S H f - -'cY a s ,.£ CE` e q 't °-'. ry - - - 'v a ° - -° ...:. 11 .- , _ - yE - - - - - 4 Gl f { ase�+✓ 23 J wlc ,e-7 cc t A, PUTNAM COUNTY HEALTH DEPAR T DIVISION OF ENVIRON(ENPAL HEALTH SERVICES 225 -0310 - r DI- OSAL SIMIU i "tC: Aik OWNER'S NAME - - PHONE SITE LOCATION ADDMSS TO IN"i'ER`iIEWID PCHD Complaint Name & Relationship (i.e, owner,tenant, etc.) TYPE FACILITY ; - PHONE roposal (include sketch locating all adjacent wells): ME: Repair must be in same location and of same type as original sewage disposal system. ifferent location may require submittal of proposal fran licensed professional engineer or roistered architect. _ x - ._ Proposal approved Inspector's Signature & Title Proposal Disapproved Date Proposal approved with the following conditions: 1. Procurement of any Town permit, if applicable. 2. Submissicn 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. SIGNATURE XS: White GaM t Yel lcw (kin BI); Pink (Aft:a ant) TITLE DATE PUTNAM COUNTY HEALTH DEPARTMENT DIVISION OF ENVIRONMENTAL HEALTH SERVICES 225 -0310 PROPOSAL-FOR S3aGE DISPOSAL - SYSTEM- REPAIR OpgNERIS JUM Warren Moscow PHONE 528 -5386 SITE LOCATION _231 141e9e:pQ �?epd' P ir�rr "�f THO MAILING ADDRESS same PERSON INTERVIBtQED PCHD Canplaint # V 7 c/- 4:4 Name & Relationship (i.e, owner,tenant, etc.) DATE TYPE FACILITY PROPOSED INSTALLER PHONE 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. see attached ?at !,or and skatch IJ 'J � V � + _ i•YV 1 /', V �•Tc (. / �G'✓J :�'1 !/ '�Z� 1 ?L._�"f' ��'���i� i1.f�'i:ti. Proposal approved Inspector's Sicrnaturdi & Proposal Disapproved roposal 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. �Ifd Iaite (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. [, as owner, or, reported agent of owner agree to the above conditions. 31GNATURE —`— TITLE DATE 7M: Wiite (FCD);; Yel1cw (Tan HI); Pink (Anlic$nt) H 41 Cold ZVI c 4 brc y A/ V4,1 /25- C.4 i t-j — v f) C--, � 'BC- t -) 'Y" 7q D t e, '6D 17 '3 3 O'kO" BE