HomeMy WebLinkAbout3299DOCUMENT CONVERSION SERVICES PROVIDED BY
IMAGING & MICROFILM ACCESS, INC.
www. sca n yo u rd o cs . co m
631- 589 -8100
73.05 -1 -3
BOX 27
03299
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PCHD Complaint #
Name & Relationship (i.e, owner,tenant, etc.)
y r TYPE FACILITY
oil
.�_ .e_ C_n , PHONE
Pro (include sketch locating all adjacent wells):
o NOTE: Repair must be in same location and of same type as original sewage disposal system..
Different location may require submittal of proposal fran licensed professional engineer or
registered architect.
21
Proposal approved `7� .
Proposal Disapproved
r000sal approved with the followincx conditions:
1. Procurement of any Town permit, if applicable.
2. Submission of as built repair sketch in duplicate showing:
a. Owner's naive.
b. Site Street Name, Town and Tax Map number.
c. Location of installed ccmponents tied to two fixed points
d. System description (e.g., 1250 gal. concrete septic tank,
drywells surrounded by one foot + gravel).
e. Installer's name and number.
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(e.g.,house corners).
three precast 6' diam. x 6' deep
3. System repair to be performed in accordance with the above proposal and conditions.
I, as owner, or reported agent of owner agree to the above conditions.
SIGNATURE �' '-".�� TITLE byab ()l& kU_,U DATE `� I
MS: Rdbe MD); YeUna (Tam ai); Pink (Appliaint) /
POTS COUNTY HEALTH DEPAR'
-DIVISION OF ENVIRONMENTAL HEALTH SERVICES .
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IV4 01 . -
SITE •'
VAILING ADDRESS
PRISM INTERVIEWED PCHD Umplaint Q
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Rune & Relationship (i.e, owner,tenant, etc.)
DATE "d 4 s / TYPEp FACILITY
PROPOSED INSTALLER �' �� 4- A P-Z r ( 1 /Oi(1 , � /�! � PH= c-� 9Q 3 }
REGISTRATION # 7746
Prowl. (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 engines or
registered architect.
Proposal
Inspector's Signature &
Proposal Disapproved
with the following conditions:
l
Date
1• Procurement of any Town permit, if applicable.
2. Submission of as built repair sketch in duplicate showings
a• owner's name.
b. Site Street Name, Town and Tax leap number.
c• Location of installed components tied to two fixed points (eago,house corners).
d. System description (e.g., 1250 gale concrete septic tank, three precast 61 diamo x 61 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.
I, as owner, or
SIGNATURE
owner agree to the above conditions. /
TITLE 06 JAICR SATE C�
OPMs vl ibe MEW; YeUco "(Tam BI); Pink (Allicmit)
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PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
s.'NR4.��:��.`�`y�.....a� - °',�. _._� -- _. '._: k -.-K .- -r.. • �. .... +me W. -f -. -Nwf 1 : :M1V o'Z...v tt .�.., +w�-��. �. -. ^a ��— r_.i
PROPOSAL FOR SE DISPOSAL SYSTEM REPAIR
OFFICIAL USE ONLY
SITE LOCATION '3 5 u, ' kc-'_ l TM# 3 • ) - 1-3
OWNER'S NAME 1O rEg k- & Vie r PHONE Y-S 52- - -y-2. -
MAILING ADDRESS 6
PERSON INTERVIEWED PCHD Complaint #
Name & Relationship (i.e., owner, tenant, etc.
DATE
TYPE FACILITY
PROPOSED INSTALLER ci- �y h �a,1c;1 �,r _ PHONE 5iV- 7 36, �S610
ADDRESS REGISTRATION# f L-� 6 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 registered architect; ; ,
I, as owner, or re
SIGNATURE
0,. w Ali - -
o_Amer a�ree_i�.t e_c onditioxis stated = ®I s Tern: - - -
4 TITLE / �i/Al�Q DATE
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 G 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 DATE
COPIES: White (PCHD); Yellow (Town BI); Pink (applicant)
PC -RP 99NII,
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