HomeMy WebLinkAbout3029DOCUMENT CONVERSION SERVICES PROVIDED BY
IMAGING & MICROFILM ACCESS, INC.
www.scanyourdocs.com
631- 589 -8100
62.18 -1-43
BOX 25
1 ru
Ir
J
L
I
ffll
`
Lm
,
03029
7/
SITE LOCATION
OWNER'S NAME
MAILING ADDRESS
PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
PROPOSAL FOR SEWAGE DISPOSAL SYSTEM REPAIR
OFFICIAL USE ONLY
38 L� qtr P� -�A, �,��rM# �. �. � � ' / • y.�3
PHONE / y 15.2 - tv a x y
PERSON INTERVIEWED 0 w Q Q (" PCHD Complaint #
Name & Kelationstilp i.e., owner, tenant, etc.
DATE J y y I I 'A oc) 0 TYPE FACILITY
PROPOSED INSTALLER %�'N O G L I4 a AD 4 PHONE `�13 `I '� � � 5
ADDRESS (o S o2 Sri c- . . X Q, — ~I , V REGISTRATION# pC /5:—' 7 0
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'Yegistered architect.'-
c�ra
5"X i fe 3 6 , spa -c. -e. -� e �'rr.'� ;
5ur'r'ou NAOCA ue/i
iis.oW,ner,.or reported agent of owner agree-to the conditibnsatAted.on this fQrm,.
SIGNATURE DATE
3'�..�''i TTTLE i1/�df DATE /� �•%
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' diam. X 6' deep
e. Installers' name and number.
3. System repair to be performed in accordance with the above proposal and conditions.
Proposalapproved_
Inspector's Signature & Title
COPIES: White (PCHD); Yellow (Town BI); Pink (applicant)
PC -RP 99ML
Z
KA4
y
i
FIN
®w fx(,
opb�4
powocu"y
A.
qA P,,—
.. i
WA I- I-
\,rx A
N
tl
J
e
1-402-
!"1A v PS, Yi¢dI,- D0 /,- 5a /- r7,rw AVF_ -
14 t
h