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HomeMy WebLinkAbout2928DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 62.15 -1 -68 BOX 24 lirm T �,'ti L Ir . kQr%- �•,L :. . „Y FPM CO " ,,y, PUTNAM oan�t EEALTH DEPAR'Il+�1T �' � ” �3 DIVISION OF MWIRMMM HEAWH SERVICFS9 ? ?— ('� f � PROPOSAL FOR SEWAGE DISPOSAL SYSTEM REPAIR /' c �NIIi' S NAME % t G- Y _ � PHCNE A aLIM ADDRESS'. G/ � /� �'�I� '� .7 ... ,- �iSON^ INTERVIEWED - ^ Complaint` # / Name &.Relationship.(i.e, owner,tenant, etc.) p� ATE TYPE FACILITY pOS EnnBTALLER' �3%?��`� °f�i9/�'w c/r' c��.�r f PHONE oposal_(include-sketch locating all adjacent wells): TE: Repair must be in same location and of same type as original sewage disposal system. fferent location may require submittal of proposal fran licensed professional engineer or aistered architect. EPLACe ei5'nO6 el 1(- 5%/5 "rE'011 Lf iN (00 o� 3 r -.,Ji fiQF�tN Io AeFA of f14tS17ii,6 SSQ5 C,, N S.-I)tYL r WRY L T-7X L Avw,) a H ' !,� A'�1� 5 posal ed Proposal Disapproved (A46 '19" i Inspector's Signature & Title - I Mal approved with the following conditions: � Procurement of any Town permit, if applicable. Submispion 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. System repair to be performed in ,accordance with. the above proposel and conditions. '. a owner,, or reported agent of owner agree to the above conditions, %TURE TITLE * to (PC D); Wlcw (%-n HE); Pink (AWlimt) cn BRADLEY CHADWICK tit. G Barger St. J2 Ff 0d77 /�' • ✓��' . • -... C%rub ask, 14. 1- 0-83 ?� �.3 y,3 S` `` . v L`1 �J • • 3 x ). *% a f xi LV �i fi, Rt. G Barger St. R iz VA V-7- t '� r - t - dam` ••O_ .. ,`t O "• ., . • 1 ~ �o a �. •4 .. � i .., _ .. . .. :_ �. -�, �� . -� , OWNER 'S NAME SITE LOCATION _ MAILING ADDRESS v PUTNAM COUNTY HEALTH DEPARTMENT DIVISION OF ENVIRONKENTAL HEALTH SERVICES PROPOSAL FOR SEWAGE DISPOSAL SYSTEM REPAIR 197 PHONE PERSON INTERVIEWED " - "� /-- "`"PCHD Canplaint # Name & Relationship (i.e, owner,tenant, etc.) DATE ZZS TYPE FACILITY PROPOSED INSTALLER ff/�T"�,-/lfZ �i %�1� % C%J' Ce-- �//% PHA Of 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. TF -PLACt eel-ls-fuiG ` 'erfis 5� S i �t�- �. �N ©� o 3 P.7; 11-i AF-C-4 pF ."cS; ?16,6 S,50S 's Signature & Title Proposal Disapproved bate 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 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 /Z�a PIES: Vhite (PAD); Yellow (Tam EI); Pink (Appliamt)