HomeMy WebLinkAbout3340DOCUMENT CONVERSION SERVICES PROVIDED BY
IMAGING & MICROFILM ACCESS, INC.
www.scanyourdocs.com
631- 589 -8100
73.05 -2 -25
BOX 27
I
I I
= I
IL
6~
-
k
'
Y
03340
SITE LOCATION
OWNER'S NAM
MAILING ADDR
PERSON
DATE 1
PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
_. P- koposn
OFFICIAL USE ONLY
R - 7 e"7 a-
VIEWED PCHD Complaint #
Name Relationship i.e., owner, tenant, etc.
0Z.
PROPOSED INST
TYPE FACILITY
PHONE S_2 '6
ADDRESS /-3. C o mil% 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 q9 proposal from licensed profession en inee or registered architect.
w S� •
..._ -1y as
SIGNAT
ow_ agee. o the conditions s+ tated,or t1n is form.
TITLE DATE 2-
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 D TE
COPIES: White (PCHD); Yellow (Town BI); Pink (applicant)
PC -RP 99ML
A, � Of . • � l `�r2
4"41
. ;�j :-
21.05
2a.°3
4or /,g
cm
t4i
LO 16
13754•
TO
NORTH
OF DI
CURVE ArH1L1--."
q4 TOP DRIVE.
fie, 4r'04
DRIYE
P4RC.El- SHOWN HEREON. KNOWN AS
LOTS /3, 14'a 15 ON ';WA P /,?/ 8 FIL ED
AT CAMEL ,,VY ON MAY 4, /93/.
crRrIFIED..To
Pur,vqm COUNTY-FEDERAL SAVINGS cl LOAN
7.t 3
—0A 9 W.,,y E Q R
JOHN YA /V,., *- R 0 5-5,
AND
,JA IVE T. VAN ROSS.*: