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HomeMy WebLinkAbout3357DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 73.05 -2 -68 BOX 27 I r . ' .. �� .. ': r. IN ,6 �. 1�� i ' 03357 PUTNAM COUNTY HEALTH DEPARTMENT DIVISION OF ENVIRONMENTAL HEALTH SERVICES DISPOSAL pRopos FOR SEWAGE REPAIR .V OFFICIAL USE ONLY (DATE LOCATION �' C it �9 ' L �- �cn. TM# `7r3 r S : (o NER'S NAME (`�► r++ ��e a- t� t 3 a a��� R, S;� RTA Ccc;c HONE 52-(� itS7 LING ADDRESS cam,, �v4 h4 V4_L+- « KJ , iO.T`2 `' SON INTERVIEWED PCHD Complaint # --Name a ations ip i.e., owner, tenant, etc. �� YY ®' TYPE FACILITY /`T' - --J PROPOSED INSTALLER 4Qw, -M, G&A-6 -T PHONE v.52 6 l S ADDRESS (,t6j" Vx t to S-7 REGISTRATION# /Z-C aL Proposal (include sketch locating all adjacent wells): NOTE: Repair must be I 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. %n G I� c�nr- o L D E �L ? (c I_U e_ cJ (O ©a 6A C l4- RE it - T i o iv C-0 sF oL r =;: ; a over; or reported al;Pnt of ' Amer agree to the• conditidris's-tatec bifthis - form. .' = ,., ----- DATE � �-Fl '%�— Z � SIGNA TITLE 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. Proposalapproved Inspector's Signature & Title COPIES: White (PCHD); Yellow (Town BI); Pink (applicant) PC -RP 99ML ATE