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HomeMy WebLinkAbout3507DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 74. -1 -5624 BOX 28 I ME 1. U1111 In ME ; r iA7 IN Lj:l rp ly, all *L0 SEE kP A I 03507 J*' 4..J PUTNAM COUNTY HEALTH DEPARTMENT DIVISION OF ENVIRONMENTAL HEALTH PROPOSAL FOR SEWAGE DISPOSAL SYSTEM REPAIR OWNER'S NAME An. Leonand Rohmen PHONE 528 -6915 SITE IACATION 66 Roc&Ue Road - Putnam Va�leu, l'Jy TM MAILING ADDRESS 66 Rochda.Je Road - Putnam Va Ueo , NJ /0579 PERSON INTERVIEWED L. Rohmea (Ownen) PCHD Cwplaint # Name & Relationship (i.e, owner,tenant, etc.) DATE gune 24, 1995 TYPE FACILITY l n i.vat e dwd i as PROPOSED INSTALLER Aaho ac SanLtaf-Lon Se ti.c Inc. PHONE 628 -4526 e REGISTRATION # 4/ 217 KennLcut . 11al Rd. - Aahopac NY. Pro (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 fram licensed professional engineer or registered architect. / / 1) / IrtataU l 2/ % I1Li- 6aflL,- I n ih 1!,7.4h0rl n/}(/ ,,1 und,,I, and rytumna l /ni •I•A /• t�O New ,��..ne /�2pii -r 'fan% In limb;on. /Cnmo J,),-f1j nn nn oy ;At nod n #nfam *No cloAa_n to ,//o//_ Proposal a' Proposal Disapproved Inspector's Signature & Title Da ' 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 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. I, as ownerf.,or reported.., a of owner agree to the above conditions. SIGNATURE TITLE DATE ?lES: WAte (PAD); YeUc w Mkn HI); Pink (ApgUa nt)