HomeMy WebLinkAbout3704DOCUMENT CONVERSION SERVICES PROVIDED BY
IMAGING & MICROFILM ACCESS, INC.
www.scanyourdocs.com
631- 589 -8100
74.17 -1 -38
BOX 29
03704
IN
IN IN5
r-
AN I
IN
y
Wbrr
IN
03704
FICITOJ2,9 71�D
PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
r
PROPOSAL FOR SEWAGE DISPOSAL SYSTEM REPAIR
OFFICIAL USE ONLY
SITE LOCATION Sd iK S44 9-- -r hF TM# -7 Vi 1-7
OWNER'S NAME Tv Ot %-k * Tv i...k A IN J4 E- PHONE
MAILING ADDRESS Ill � z t i ? `j'
PERSON INTERVIEWED PCHD Complaint #
ame & Relationship i.e., owner, tenant, etc.
DATE 'l TYPE FACILITY
� PROPOSED INSTALL HONE �i S� 5-7-6 a S'13—
-Qv GISTATION #fI3 ADDRESS�q6 Y
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.
r.. LsTr ►� C i'4* 4 tct °- ggco4.
_UV 1-7 / o a N S C C,0 S t.-s i,
.4
�
_, I, as_ owner o reportgd went of owner agree" to _the .conditions state.: ou this.fonm._
SIGN 2&&4e9l 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
t+IL E�-
5 �-#W-* Lo�.4
DATE
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
e. Installers' name and number.
3. System repair to be performed in accordance with the above proposal and conditions.
approved. Proposal
Inspector's Signature & Title
COPIES: White (PCHD); Yellow (Town BI); Pink (applicant)
PC -RP 99ML
DATE
PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
OFFICIAL USE ONLY
Wo ° i 39
SITE LOCATION / 2 .� l� -� ��- ��; ��✓t�- TM# 0 —l// t-47aa a 5rC—' z576V °G t
OWNER'S NAME 'O f PHONE
MAILING ADDRESS
PERSON INTERVIEWED ee- PCHD Complaint #
ame & ations ip i.e., owner, tenant, etc.
DATE l% TYPE FACILITY
�� cis
PROPOSED INS ALLER 61 "ell PHONE
ADDRESS 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.
I, -as owner; -or reported agent of o gr to the conditions stated on this form:
SIGNATURE (�C ; �'� f TITLE 7
Proposal approved with the following conditions:
1. Procurement of any Town permit, if applicable.
2. Submission of as built repair sketch in duplicate showing:
DATE
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 approv
W,Wrtmarm
Inspector's Signature & Title
COPIES: White (PCHD); Yellow (Town BI); Pink (applicant)
PC -RP 99M L