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HomeMy WebLinkAbout3814DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 83.12 -2 -1 BOX 30 170-WI, me NO 'A �. 1, �` i. - �.�., L i In '- .� W, . 03814 OWNER'S NAME SITE LOCATION PUTNAM COUN'T'Y HEALTH DEPARTMENT T I DIVISION OF ENVIRONMENTAL HEALTH SERVICES P1 fbR 6EN� bISPOSAL 'SYSTEM REPAIR r. Z- L) / C G A WA N MAILING ADDRESS 03 r A ►1A /SSA • a • r ar• a a� DATE A, / 1 ) e-. H y 12 c 14 PHONE 5"Z -8 -39 s8 RD P1 /Vm !o571 Complaint # zship (i.e, owner, t, e —.) D n v TYPE FACILITY %5 14 / PHONE 73q-2— S' 2- 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. ON& r#oa5r NO 6T!t[ -La/-1 YIlc- 5,619M- I-Ad k Yn l C- l/ 5rA1, LFD , W l fihl d© g h r/ N — Proposal approved— — Inspector's Signature & Title Proposal Disapproved with the following conditions: i - Date 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 c mponents 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 owner, or reported agent o owner agree to the above conditions. SIGNATURE . er - TIM , LD��;C PATE PIES: White (PAD); YeUuw MyAn HI); Pink (AppUamt) l S i; �f Y 2�2 Cl l 11 H 0 .. rrdlvi �4�Vfj, - ►t�Aom i QQ y llp4 A-3 -1-A0 W YN -1194 0 Vo � �N �� W-;P50 V XY i