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SIGNAT[JR ,ter
PUTl`?A1V! CtOtJNTY HEAT TT4, DF ARTjV(ENT
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' DIVISION:OF ENVIRONMENTAL HEALTH SERVICES
PROPOSA"QR SEWAGE DISPOSAL SYSTEM REPAIR- ;
. 'P'ro "on sal 4UOv, ed:with the following;'condttions f - _
'1 Procurement of any Town permit, if applicable
OPFICIAL'USE ONLY
2 Submission of as ,built repair sketch m duplicate showing
a Owner's name
e
Site `Street Marne; Tovini and Tax Map number::
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. SITE. LOCATION TM#
OWNER'S -.NAME L 4-,Z " "'r f` . '�
PHONE -
MAILING ADDRESS . = .irw
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.
PERSON INTERVIEWED W r� ' , -
PCHD.,Complaint # z° fry
am ET a ations p r.e ,owner, tenant, etc
-DATE �.,
TYPE FAITY:
CIL t�
PROPOSED INSTALLERu,sy i 'r't
'D, � Un- x E -y
'ADDRESS . U. f= rtijE'{JsT�r� REGISTRATION#
Proto sal (include sketch locating all adjacent wells).°
NOTE Repair must be iii same, location and` of same type as original sewage disposal,. "system ,Different location`
mayrequire submittal of'proRosal from licensed ;professionah engineer =or. registered architect
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APsYI + r�i tL '1 �' car i � ` � ,i � lei S� i�� 11, L a"c
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I, as owner, or reported agent of owner agree =to the conditions stated on this form-
4. A y
SIGNAT[JR ,ter
- .t f
TITLE' DATE
. 'P'ro "on sal 4UOv, ed:with the following;'condttions f - _
'1 Procurement of any Town permit, if applicable
2 Submission of as ,built repair sketch m duplicate showing
a Owner's name
Site `Street Marne; Tovini and Tax Map number::
c Location of installed com onents tied to two fixed oirits e: ;house ;comers
d 1;- System descnption (eg., 125Q gal ::!:Concrete septic tank, tliiee precast 6' dam- X 6' deep
e Instalhers' name and number;
System repair to be pe ° ormed m accordance with °the above proposal 'and conditions: =
r
Pr posal approved t�
f
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d, .
pector's Signature &Title DATE
!
COPIES White (PCHD), Yetlow1 (Town BI); Pmlc (aPPli� {)#
99ML� t `
PC.RP i
e �;
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MAD ( e.600,• WOW bvdl MM f"t-TI-D V
PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
• y3_.- 1p.n`rt_ ;mss..- ..._._. •._.G ?..`.. _ter•._ V •r�..�..4yr, .v.�.f4- - -1.•r j-+..1 \. v -C
°i�R�)PUSAL'(lR SEWAGE DISPOSAL SYSTEM REPAIR -
OFFICIAL USE ONLY
7 'cagq�
SITE LOCATION 39
S
Al.(J K1e&
TM# N07/-/-9
OWNER'S NAME
&AE0A11UL
PHONE
MAILING ADDRESS
PERSON INTERVIEWED J46i -OmSKl PCHD Complaint # !U A
ame & Relationship i.e., owner, tenant, etc.
DATE TYPE FACILITY/64 i V#7&2)kA6Zu y_
PROPOSED INSTALLER\,1,4t),�- OOSK11 °i-SO►I) . , /) 2- PHONE
ADDRESS /af/cSldo p;�/ 44fidPW,1Ve110"5-// REGISTRATION#
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.
54
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"12 yc2C5 WAARZ PE(ImXr To 6E X:MCD .f3 J -TRf =S a"A27i4,10A!•r J;5"+1000 64Lta ti
CAN °r•gf_ &j srMcco, dtfl"_ o10tr-PA RcDrt 99fott -6 Zsroc•�rxsw.
PG S E tj o -rr_ F�J pcoj+ NSgpofao 5fiCa'r- u XAj G FIDrz AIU OA" c ro ur �rnrs Pr c rto1V ,
..._J,_aS:owner;:or_r_epnrted agep± ofnwn -er.a eF tvi11e c.o!-.L4 �gns_ d 1 hi-s c )tlj
SIGNA TITLE DATE
Proposal =roved 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 comers).
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 pe ormed in accordance with the above proposal and conditions.
Pr
posal approved
9W;
s Signature & Title
COPIES: White (PCHD); Yellow (Town BI); Pink (applicant)
PC -RP 99NE
DATE
/0/23-
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