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HomeMy WebLinkAbout3202DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631 - 589 -8100 72.19 -1 -15 BOX 26 L is eir�7 J 1 � X71 � 1 rj I . T ' . se 11, � *r is -Wbrr or T 03202 SAM cOG A P PUTNAM COUNTY HEALTH DEPARTMENT DIVISION OF ENVIRONMENTAL HEALTH SERVICES PROPOSAL FOR SEWAGE DISPOSAL SYSTEM REPAIR OFFICIAL USE ONLY 3 36 r7 -0a SITE LOCATION C1 - �/� F 'u -r (� uo k TM# 7,� , 19 -- 1 OWNER'S NAME \,U t LL I f9r - P -Ai1e( PHONE ^ 6 69 i MAILING ADDRESS )ul ,7-4 PERSON INTERVIEWED PCHD Complaint # ame a ations p i.e., owner, tenant, etc. DATE I 'v TYPE FACILITY R <6S PROPOSED INSTALLER O 6t'z,14-6f-A1-r1—PHONE 5 ,46 ' C-X( (0 VS ADDRESS 14* 103 -2 REGISTRATION# PC i 8 P=osal (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. RJI r Lo G H--n o I, as owner,' o reported agent 'of owner agree to the conditions stated on this form. - SIGNA �i.;U TITLE DATE-' V17 O `—t-- 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 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 performed in accordance with the above proposal and conditions. Proposal approved_____ Inspector's Signature & Title ATE COPIES: White (PCHD); Yellow (Town BI); Pink (applicant) PC -RP 99ML