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HomeMy WebLinkAbout3510DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 74. -1 -5633 03510 .� �z Z��163L , ` �� i1� 03510 PUTNAM COUNTY HEALTH DEPARTMENT DIVISION OF ENVIRONMENTAL HEALTH SERVICES SITE LOCATION OWNER'S NAME_M MAILING ADDRESS OFFICIAL USE ONLY TM# PHONE 1416 - 5,zg - 9 .1 5Co PERSON INTERVIEWED Mrs, hac aids 0U--)cVV.f PCHD Complaint # I Name& Relationstup (i.e., owner, tenant, etc. DATE 2MO t TYPE FACILITY ,PHONE *15- ` 2Ao- 05'1 ADDRESS'S t��D.,►,�va., R'I �cri L.rm. L IC52y_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 of proposal from licensed professional engineer or registered architect. �.- - -1 C1: i r - r► % % - - .. __%_._ L. .I- 1 - iar-.f e(-, ..-1i . I .. owner, - or,reported agent of.owner..agreeao.the condittiio�n�s stated, on this form. SIGNAT TITLE �,.� �����6 �!Z�... - DATE 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 COPIES: White (PCHD); Yellow (Town BI); Pink (applicant) PC -RP 99ML V/ ©� DATE e� Mr. and Mrs. Kaminsky Three Arrows Cooperative Society 63 Rochdale Road Putnam-VaUey, NY 10579 (945) 528 -9256 f System Description: Installati ®n of 1,000 Gallon Plash Tank and 180' of 4" Perforated PVC with Gravel. Installer Ply I'� nforte P�fessa tai 11scap ng 3 Rocba, Road Garrisoa" NY 10524 (845) 73� -0571 Homedw'ner. Mr. and Nft. Kaminsky llaw A)Tows Cooperative Society I /'I:. —I)f)