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HomeMy WebLinkAbout3820DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 83.12 -2 -45 BOX 30 03820 99, Aim oil I JU 03820 R QV�r4of V,1 GL-,Kj PUTNAM COUNTY HEALTH DEPARTMENT . fY � Ito DIVISION OF ENVIRONMENTAL HEALTH SERVICES L- ;O`aQS7, FtJk bEC DISPOSAL SYSTEM REPAIR '1 OWNER'S NAME E-Q ('Z/4pt4h% PHONE SITE LOCATION 0564� ./v ' LB,#9 al j 5o u -rc4 S", ma R-3. 12— a — V5- MAILING ADDRESS Cld 4. (9A+� X�-T s,J-9,6 ©S C. P, � . ?u - Wi0,A 1% "v . ,V �Y. o 1-95' PERSON INTERVIEWED MM Complaint � Name & Relationship (i.e, owner,tenant, etc.) DATE TYPE FACILITY ® Aq of. FC-;- PROPOSED INSTAI,T FR 44v w #m 64 nc d k o�-c F4 PHONE Proposal (include sketch locating alf 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 fram licensed professional engineerr or registered architect. .. Ira I G 66 w1getv ove #-L ACM , r4fxa- T 'roposal approv Proposal Disapproved Inspector's Signature & Title Date - oposal approved with the following conditions: L. Procurement of any Town permit, if applicable. 1. 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 ccaWnents 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. . System repair to be performed in accordance with the above proposal and conditions. as owner,, r reported agent of owner agree to the above conditions. NATURE TITLE DATE j v2a3 Ir ;: ftbe (PAD); Yellrow (Rin H[); Pink (Applicant)