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HomeMy WebLinkAbout3845DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 83.12 -3 -23 BOX 30 K11 %6 r .1 'L 6 I` �1 I . +' �'� 03845 P"', PUTNAM COUNTY HEALTH DEPARTMENT DIVISION OF ENVIRONMENEAL HEALTH SERVICES OWNER'S NAME /Q .0•' -t'. S :7e- Te.,2 PHONE SITE LOCATION ©' r te- c/ / TO Complaint # <f-o--,t9 Name & Relationship (i.e, owner,tenant, etc.) g 3 DATE TYPE FACILITY PROPOSED INSTALLER PHONE REGISTRATION # Pro (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. Proposal approved Proposal Disapproved 's Signature & 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. 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' diem. 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. :, as owner, or reported agent of owner agree to the above conditions. 1GNATURE 5 'a°j`�' TITLE DATE IES: White (POD); Yellow Mkn ED; Pink (ARiLiant) n II 09 20 II mF m $ ? s a0 + O t. z IT RD ®rp per o CT f ' s 1 Y f 4 O L4 90 UO`579 �i o n H / Brook C"u § rUTNAy ? ALLE g o Crofts j Corner . 1057 CO II o l as K h �A\ II �� R '? w J2 y E >" �lhou use'um (� Kin A i 0:, dams W orne rs W h a Cem Rose Hill Park Cem fZ Q L X20' W s�yG eu:en _ ... TN RD WN �o u 23 ' o / IN° rn Vol WOOD RODE it R ¢ "'� ='• s Ena a �•�.'"-.�- S �� �..� ii _ � y �y TY ®- r lie �P° JHS® �� TNA� CO �--- ®UNTI' Brook 1 I - 1 11 e� CO 1 Z .O Hapstrom Map �p%�� �!®® @��q 9 1 �P 1� O .I Company. Inc. IntlohegaE@ Lake, (3 \ rj PUTNAM COUNTY HEALTH DEPARTMENT DIVISION OF ENVIRONMENTAL HEALTH SERVICES PROPOSAL FOR SEWAGE DISPOSAL SYSTEM REPAIR. 77-1 OWNER'S NAME -e Is PHONE SITE LOCATION 2 d , e— c/ TM# MAILING ADDRESS PERSON INTERVIEWED PCHD Ccmplaint Name & Relationship (i.e, owner, tenant, etc.) DATE TYPE FACILITY PROPOSED INSTALLER PHONE 6 — /;F 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 fran licensed professional engineer or registered architect. *'�pos�l'appioved-'(/ L-� Proposal Disapproved Is Signature & Iroposal 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 I s name. b. Site Street Name, Town and Tax Map number. c. Location of installed ccmponents tied to two fixed points d. System description (e.g., 1250 gal. concrete septic tank, drywlls surrounded by one foot + gravel). e. Installer's name and number. (e.g.,house corners). three precast 61 diam. x 61 deep 3. System repair to be performed in accordance with the above proposal and conditions. , as owner, or reported agent of owner agree to the above conditions. IGN&TURE -5— f, � TITLE PATE ES: Wiite (PM); YeUw Mkin ED; Pink (Appliom-it)