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HomeMy WebLinkAbout3744DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 74.19 -2 -9 BOX 29 03744 ,, 1 � L1. iL _ Ill - LL �LL , 1 03744 PUTNAM COUNTY HEALTH DEPARTMENT DIVISION OF ENVIRONMENTAL HEALTH SERVICES .... ., ....., -, .._...... �. - .::...., . ,;.._ .....E - ... �.... .. �. _ ._ .. _. .� .... � -�. - .. PROPOSAL FOR SEWAGE DISPOSAL SYSTEM REPAIR • OFFICIAL USE ONLY - y V SITE LOCATION �s /�5� ZAP/* *, — TM# r7q, fq —cl NAME Rleen PHONE g15- SoM (10 7-2 MAILING ADDRESS PERSON INT RVIEWED H I [ of 2e -l�,i ^`� PCHD Complaint # "Dame & Kelanonship (i.e., owner, tenant, i c. DATE PROPOSED INSTALLER_L ADDRESS CX-4 ✓.a-7`i tp- TYPE FACILITY •1,M P /a("' PHONE 26fii�7�6l sG' REGISTRATION# ®•y°-0 � 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. (1P,up PU dH P n I d IL On - i III i/ . -yZ 4�- Kwi o+ 1/, he � n � _'Z� n� r c• n 'i n_ e� -�s �h �c� dry: wee. I P`� �� . f!o w211 s. t�'1 � �n . _►�© e� .. -i; eS'6W'1 cr; or Ire u ed'a�eenvof owner agree io the "condirioris stated'on "tlus'form: ' SIGNATURE / TITLE ems`' 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, 'Gown 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. & Title DATE COPIES: White (PCHD); Yellow (Town BI); Pink (applicant) PC -RP 99ML rRAL -KIJCK C.... VATING 0 �bv�j le'v G /(- P.O. BOX 395 : - mahopac Fans, New York 10542 'ao'l 914-248-6148 A7 �J oly /�So lie- av t� 7, I✓o /Vowe 47 '/ 5' tA2y k/el ED KU - CK.EXCAV INC.. NC 411(,44 QAA 01900% P.O. Box 395. dices ���„� Mahopac Falls, New York 10542 914 -248 -6148 C. ivy io,5 y/ 53" 68' 976 O w 3 2 J is, -s 62' 63'B`' !l6 IS'6 a x Q _ �_•. z