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HomeMy WebLinkAbout2989DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 62.17 -3 -19 BOX 25 ;x'-91 -y. ' . IN t. . ■ ' ' -. . ` . - ., . . to PUTNAM COUNTY HEALTH DEPARTMENT DIVISION OF ENVIRONMERrAL HEALTH SERVICES -,2-25-0 PROPOSAL FOR SEDGE DISPOSAL SYSTEM REPAIR _a _ 7U OWNER'S NAME SITE LOCATION q0 MAILING ADDRESS ?VL, &v- -4- PHONE SZ.4 — 23 0 To 5-,y 30 PEPSON INTERVIEWED PCHD Complaint # Nam & Relationship (i.e, owner,,tenant, etc.) DATE 1111140 TYPE FACILITY PROPOSED INSTALLER SJ*V, CSIIIIAI--iL� 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 iodation may require submittal of proposal from licensed professional engineer or registered architect. 91 111 0. I �b,-- WrkA to e- Vv, aA-- V elf- Proposal approved Proposal Disapproved � Inspector's Signature & T* natA Proposal approved with the following �nditions: 1. Procurement of any Town.pemit, it 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 61 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 re g of owner agree to the above conditions. SIGNATURE TITLE tmq DATE 111662 -n-L R,-, 5,G.-J%%k ► pl- W-Abe (KHO); YeUcw Mun ED; Pink Uqlicant) 16S11. If OMER'S NAME SITE I=TION . © MILING ADDRESS PERSON INTERVIEWID Dame & Relationship U.e, owner MU S HOME 5---2 � -- 2 30.E ,m# �57- 7--1 -- 0,�5� 5> POHD Complaint # ,t6 -Ant, etc.) HYPE FACILITY �- /1 u PHONE ry ,C— ? — 3 o YG Emnal (include sketch locating all adjacent wells).: NOTE: Repair must be in same location and of same type as original sewage dispopal.systema Different location may require submittal of proposal fran licensed professional engineer or registered architect. .1-6 v/ G -h Proposal approved — Proposal Disapproved ' Inspector's Signature & Tktre Date Proposal approved with the following conditions: 1. Procurement of any Toum 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 canponents tied to two fixed points (e.g. ,house corners). d. System description (e.g., 1250 gal. concrete septic tank, three precast 61 diam. x 61 deep dgywells 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 canner, or reported agent of owner agree to the above conditions, SIGNATURE TITLE DATE : V bite MV; YeUcw ('inn BU; Pink (k#iauit) I I i V 11 -R4, 17 /j 7-//g lqxgz- if 02 . 7r iw -'eat 7 zr.; TRAIA' PUTNAM COUNTY DEPARTMENT OF HEALTH :`"DIVrSION OF ENVIRONMENTAL ,HEALTH SERVICES Re Property of C_ Date Located at (T) Lla,. '�g��et,y Section S L Block f. . p Lot 30 Subdivision of ,Subdv. ° Lot # Gentlemen: :Filed Map # Date This letter is to authorize 2FUL>Z a duly licensed professional engineer or registered architect ( Indic'ate to apply for a Construction Permit for a separate sewage system, to serve the above noted property in accordance with the standards, rules or regulations as promulagated by the Commissioner of the Putnam County Department of Health, and to sign all necessary papers on my behalf in CO3rxIacAioil with this matter and to supervise the construction of said system or systems in conformity with the provisions of Article 145 or 147, Education Law, the Public Health Law, and the Putnam County Sani- tary Code. Countersigned: P °E° a 4, # -3 27 2 Address �G S- *0 /g Telephone Very truly yours, o Signed ' Owner of Property q o A, Address Town Telephone ........ . I -S. - --- -