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HomeMy WebLinkAbout3522DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 74.- 1 -SC 12 BOX 28 ,Iry I 111%. IN L. L 6 ,, Ymi :-rL' f �y� F `yr' 03522 a r SITE LOCATION , OWNER'S NAME_ MAILING ADDRES PERSON INTER DATE PUTNAM COUNTY HEALTH DEPARTMENT DIVISION OF ENVIRONMENTAL HEALTH SERVICES . .- .w-. .. •. .,- -+i. r. •.r .. _.c.... .. ...., � p...: e. is .� r. .. .. - ,. .... =-...: . .. PROPOSAL FOR SEWAGE DISPOSAL SYSTEM REPAIR OFFICIAL USE ONLY 5- RAP . TM# 7 V, I k4R PCHD Complaint # ame k. RelatinnOin i i_e__ owner. tenant etc. PROPOSED INSTALLER J-4jda/ &N19 (��, oZ �� v SCR I, ,4- MA LK . ADDRESS it;a;_Lc it . &i TYPE FACILI ;Y . K 6 S PHONE if g S r S-a 6 aRf S- REGISTRATION# PC. / 3 � 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. 01W 8 �u a %A S q,*- so mac;. A-�E Ce ►i. AV m vrd U 6 rc -& ! _ -' �f L46C 'Rd r -r r-.o Y' E rL C. T4 M �G i JAV ow I; as owner, SIGNA of owner agree fo'the conditions itated oa this form. i TITLE ;TTY �� .r Proposal approved with the following conditions: 1. Procurement of any Town permit, if applicable. 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 rformed in accordance with the above proposal and conditions. Pro osal approved pector's Signature & Title COPIES: White (PCHD); Yellow (Town BI); Pink (applicant) PC -RP 9ME DATE I I a l T u/ 'V-Ko- 5) C11-1 U `t- m- F s We coo 't coo — c� .44 L�-q R�vw 1 .'v � r-t-r-o A-330 T c ,1.0 .tp rJ o P L T w r i3 f9-�� /�� (•c — ,L L -T Al—' IV v -- J U I j Q a qt, r scnw,,F) i4A L f4 D /000 6A4. ptvc fiA k C J C�. � J cd C 7 (01 c CltT U b d M � -T)4 RE ` L) � 0 i 138- y. tit 4c(—(CS 'Xilf 6.44 V C(, 0-C-() 7WHk CowslL,5 -tu iza'a.0 -j J CJ d- F 3o' 4c(—(CS 'Xilf 6.44 V C(, 0-C-() 7WHk CowslL,5 -tu iza'a.0 -j J CJ w I