HomeMy WebLinkAbout2875DOCUMENT CONVERSION SERVICES PROVIDED BY
IMAGING & MICROFILM ACCESS, INC.
www.scanyourdocs.com
631- 589 -8100
62.13 -1 -60
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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 from licensed professional engineer or
registered architect.
Proposal
s Sianature & Title
Proposal Disapproved
If P//1-
Proposal approved with the following conditions:
Date
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 ccmponents 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
drywalls 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 agen, of owner agr to the above conditions.
SIGMA ✓ TITLE 0WArP/)c0_ DATE
PISS: White (P M); YeUc w (fin HE); )
PUTNAM OOUNTY HEALTH DEPAR24M
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
Y
PROPOSAL F'UR `SE(KAGF; DISP09AL SYST& REPAIR
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OWNER'S NAME AAA,
H u1-TAV i VtM LML WM HVCrAR -1 PHONE
q1q -5 Zii
° 19,7?2
SITE LOCATION 44
M t v c. P U N W Vftc tom' O i 710
MAILING ADDRESS 5 7
btw-o j PiL , PtlNMA i1Aur�- -(� �3 ;'{ i.0S79
PERSON INTERVIEWED
PCHD Camplaint #
N%s
Name
& Relationship (i.e, owner,tenant, etc.)
DATE i �t� ?j
_
TYPE FACILITY �,ti6LL- t'Am, ges,
PROPOSED I;BTALLER
CLO56
�"4_) (�� c# WA TV" - PHONE
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 from licensed professional engineer or
registered architect.
Proposal
s Sianature & Title
Proposal Disapproved
If P//1-
Proposal approved with the following conditions:
Date
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 ccmponents 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
drywalls 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 agen, of owner agr to the above conditions.
SIGMA ✓ TITLE 0WArP/)c0_ DATE
PISS: White (P M); YeUc w (fin HE); )
JOHN D. LaSPALUT'O o ARCHITECT
3613 S. Procyon
LAS VEGAS, NEVADA 89103
(702) 365.1510
TO &WigAl
61;51?77C j ? -7'W. 2vt fir:
LEETTEER OF UMRZEFTUR,
DATE i� 9� JOB NO.
A�TEIJ Tj vkt. ., .. ..• .. .. .
LTI
> WE ARE SENDING YOU P('Attached ❑ Under separate cover via the following items:
• Shop drawings ❑ Prints ❑ Plans ❑ Samples ❑ Specifications
• Copy of letter ❑ Change order ❑
COPIES
DATE
NO.
DESCRIPTION
t
•
For your use
ran �:b 5eLji46,E O(Sro s,tc, 4ePM 2
Approved as noted
❑ Submit copies for distribution
> ❑
P
❑
Returned for corrections
❑ Return corrected prints
For review and comment
❑
V❑
FOR BIDS DUE
19 ❑
PRINTS RETURNED AFTER LOAN TO US
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•
For approval
❑
Approved as submitted
❑ Resubmit copies for approval
•
For your use
❑
Approved as noted
❑ Submit copies for distribution
> ❑
As requested
❑
Returned for corrections
❑ Return corrected prints
For review and comment
❑
V❑
FOR BIDS DUE
19 ❑
PRINTS RETURNED AFTER LOAN TO US
REMARKS
Ptao5e ge l y" CyA(iu 01yj� Cf1- Wi0 (2'0y&-e— r Ocy Nt7c
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COPY TO /(yts
SIGNED:
PRDDUCT20.3 es ine, GM M= 01471. If enclosures are not as noted, kindly notify us at once.
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