HomeMy WebLinkAbout2812DOCUMENT CONVERSION SERVICES PROVIDED BY
IMAGING & MICROFILM ACCESS, INC.
www.scanyourdocs.com
631- 589 -8100
62. -2 -43
BOX 24
rZ. L
J
`
tr,
�T� . i
1, +,
r - I 1 r
ILL L
02812
PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMERrAL HEALTH SERVICES r
PROPOSAL FOR SEWAGE DISPOSAL SYSTEM REPAIR , 1
OWNMIS NAME To (ui& PHONE _S oA D �;�l
SITE LOCATION y'c}-5 01, C Aw,g LA Ke_ R_cat TO
MAILING ADDRESS 2,A n r-nn
PERSON INTERVIEWED PCHD Camplaint #
Name & Relationship (i.e, owner tenant, etc.)
DATE Py ;U i aQ i TYPE FACILITY
PHONE LP g— / f ?
�l 3�t -c�v66
Proposal (include sketch looting 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
s Signatlure &
Proposal Disapproved
Ddte
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' diem. 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 G')2,c11_. _. TITLE lC dL DATE ==-s =� 09 4 li 7. p
PBS: Mite MD); YeU w Mun BI); Pink (Applicant.)
STATE OF NEW YORK GENERAL OBLIUATION LAW SECTION #11 -104. BAD CHECK WRITERS ARE LIABLE
FOR THE FACE AMOUNT OF THE CHECK PLUS TWO TIMES THAT AMOUNT IN DAMAGES.
IF CREDIT IS EXTENDED THIS INVOICE MUST BE PAID WITHIN TEN DAYS OF RECEIPT
A FEE OF $10.00 WILL BE CHARGED FOR CHECKS RETURNED.
-01
739 -0060
4
RELIABLE SEWER SERVICE
364 Canopus Hollow Road
Peekskill. New York 10566
STATEMENT
-7-
_
DATE'