Loading...
HomeMy WebLinkAbout3104DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 62.71 -1 -15 BOX 25 R ., , IN WAJ Z ., r ,� , , tiT 61., 03104 PUTNAM COUNTY HEALTH DEPARTMENT DIVISION OF ENVIROIZNTAL HEALTH SERVICES 2n5-3938/225- 3833/225 -3641 PROPOSAL FOR SEPg1GE DISP04AL 'SYS fA RkPA1R ".. SITE LOCATION ���_ ��fi�i9G7.s1 YTX�1„ L/ALLry JS/ (r TM# MAILING ADDRESS PERSON INTERVIEWED PCHD Complaint # Name & Relationship (i.e, owner,tenant, etc.) DATE TYPE FACILITY 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 subrm � i censed professional engineer or registered architect. �) ^ -� j R S `lam � 411 k s4 (%W-Jtit) WCis,c,� _.Si�U%l'�UJ ✓hoc:. VV �L`�,�_...�_._. _...'.�'�. ._ . � .. ...o. ..:. _ .. - . -. .... Proposal approved Inspector's Signature with the Proposal Disapproved conditions:,, . S-1// -u /,[ r Da 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," ints (e.g.. hous e 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. i14 I, as owner, or reported agent of owner agree to the above conditions. SIGNATURE ���� TITLE IPgS: W to MU); YeUcw (Tom ffi); Pink (AR11aknt) ` DATE