HomeMy WebLinkAbout3014DOCUMENT CONVERSION SERVICES PROVIDED BY
IMAGING & MICROFILM ACCESS, INC.
www.scanyourdocs.com
631- 589 -8100
62.18 -1 -12
BOX 25
03014
■�
y
.,
1
T '�;
■
.L
T
T
IN
lip
r
IN
IL
amn
03014
SITE LOCATION
PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
OWNER'S NAME_
MAILING ADDRESS
T. U R OFFICIAL USE ONLY
000-61
I G� 0 -
1 � TM#
PERSON INTERVIEWED PCHD Complaint #
Name & Relationship i.e., owner, tenant, etc.
DATE
PROPOSED INSTALLER
ADDRESS
7%I
REGISTRATION#
Proposal (include sketch locating all adjacent wells):
NOTE: Repair must be in same location and of same type a's original sewage disposal system .Different location
may require submittal of proposal from licensed �p/rofessional engineer or registered architect.
L ( C n UV6 L iS Ajar. /t � CYrt r /Gtf-kl,/ d � 4 dr.1 L —
I, as_owner; :or-reported agent of owner agree to the conditions stated on this _farm..
SIGNATURE TITLE '
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 r
DATE 2
b. Site Street Name, Town and Tax- Map number.
C. Location of installed components tied to twfi xed points (e.g.,house corners).
d. System description (e.g., 1250 gal. Concrete septic tank, three precast 6' diam. X 6' deep
e. Installers' name and number.
3. System repair to be performed in accordance with the above proposal and conditions.
Proposal approved_
Inspector's Signature & Title
COPIES: White (PCHD); Yellow (Town BI); Pink (applicant)
PC -RP 99ML
6PI
D T
i4a�
--lake nd 8.6842
DIGESTERS
IMHOFF TANKS
SEPTIC TANKS
CATCH BASINS
BOOSTER PITS
OIL PITS
OIL STORAGE TANKS
INDUSTRIAL SLUDGES
Lake Drive
Lake 'P ekskill, N. Y.'
ANY TOWN OR STATE DRAINAGE BEDS
SEPTIC TANKS
K. 'R. LIETZ & SONS CES'S.POOLS INSTALLED
Raymond K. Lieta & Kenneth J. Lietz -CITY DIS. PLANTS
Owner fr Operator
1
4r7
'ev
6%
A
1-3 ru I[ -- 5-/ (?S vc-
A
A 40/
:fz)/
0 /7. 5' AvZ
V'.