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HomeMy WebLinkAbout2671DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 61. -1 -19 BOX 23 I,yS. r IN i I LI ` '' IN ■ 1 L T f ' T • ' 02671 i . a. PUTNAM COUNTY HEALTH DEPARTMENT DIVISION OF ENVIRONMENTAL HEALTH SERVICES 225- 3838/225 = 3833/225 -3641 D .PROPOSAL FOR. SEWAGE - DISPOSAL SYSTEM REPAIR IW f 17 [ii Y 0 OWNER'S NAME Edrn o h d M A t t' O 1" PHONE 52- G -'37 5 7 SITE t A C A T I O N C g ^ o ,p d, r f!�v //a 41V /Z 11 .. T K# S 7 ` CL s , 1 4nan�r a,w MAILING ADDRESS C � /� 2.P Py te, a #1 V R I/ G- V /V- Y, . /01-701 PERSON INTERVIEWED Cad tt�'v PCHD Complaint # Name & Relationship (i.e, own tenant,-etc.) DATE /I! /87 TYPE FACILITY PROPOSED INSTALLER rq.n p,, r CO --) s tr+ u. A 410 A L o PHONE 5 2 G^ f ,5 (- VI 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 fran licensed professional engineer or registered architect. -'a[l 2©o PoPr �,�t�'r PIES: Rdbe WD); Yellow (T,.vm ED; Pink (Aniicsnt) Proposa ppr ed Proposal Disapproved AWO 0 4 -?1- spector's Signature & Title Efate Proposal approved with the following conditions: 1. Procurement of any Town permit, if applicable. I 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. Gt�iy (.B�Y SIGNATURE r�4 TITLE DATE PIES: Rdbe WD); Yellow (T,.vm ED; Pink (Aniicsnt) A° 09 E ti v: '`D�211d COitdUtGL�(OIt CD. r!'`," 90 ` O A. IQ al&LLDm fid. x I � A' q- .40,Z 8.88Z SP re . tia �x.JTo.9Z Rcees ec' tl , +•,, If C? I +4 t Wf vy _ � it ►r � \ � G% � ��+ \,� l s t SS �Isr ,+ 41 •, Q. r 5, I 7 > -- oo "W 9.22• CENTS [ L /NE qP SUS /`iOLLOW B�;ooK IV/NGJ B 9Nt fvcaarcE Co, HGENCY 37 /983 SORE ROMEO is l.mrd .1'rn'v•rrnr AGE ROAD NEW YORK ALBAO i I /N 6ROVwo \ \\ �,' o '•�, i :V 3 9- se ROA NOLLQW c CANOpv5 r certifica +ions hereon are valid for this f and copies thereof only if said map or "it is hereby certified that this survey was prepared ip accordance with the existing` Code of Practice for Land Surveys adopted' Certifications hereon ar