HomeMy WebLinkAbout2991DOCUMENT CONVERSION SERVICES PROVIDED BY
IMAGING & MICROFILM ACCESS, INC.
www.scanyourdocs.com
631- 589 -8100
62.17 -3 -30
BOX 25
02991
.��
r
16
WL
02991
PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENIAL, HEALTH SERVICES
'1W20SAL rwi '01Ss
i(g�- �(c�irt�d •
OWNER'S NAME 1—f2j4- iy m -Ad i j�t i r-A -1c, 0 Ft,� S' U PHONE 916 •'oL frJ `"L
SITE LOCATION 1 at y✓ 19 U E- To 3 .36
MAILING ADDRESS PV -r-NAM UA ti, F- 1 0 5-9 a
PERSON INTERVIEWED PCHD Canplaint #
Name & Relationship (i.e, owner,-tenant, etc.)
DATE U / to TYPE FACILITY
PHONE 2 "- 02 �—
REGISTRATION # ( 3
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 from licensed professional engineer or
registered architect.
tc > , e n e" 11.6VA I
d"%
. ".-
Inspector',§ Signature &
Proposal Disapproved
1�-I-�-h
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 canponents 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, r reported agent of owner agree to the above conditions.
SIGNATURE TITLE TITLE e/'• 'L r DATE tt v C �ca
IPI6: V&te (PAD); YeUcw 03m SI); Pink (Afptiamt)