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HomeMy WebLinkAbout3935DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 83.50 -1 -51 BOX 30 , 161 .r jr Ir 03935 Howard Cragert PUTNAM COUNTY HEALTH DEPARTMENT 296 Oscawana Rd. DIWGIGN 0F:- v'iRa- W1AL - HEALILH SERVICES - PtibUnj Vgaj i; Ny -10519 225 -0310 PROPOSAL FOR S30M DISPOSAL SYSTEM REPAIR OWNER'S NAME Me, j"/►�+4 � � � � �"�Pl PHONE t;' Z � -&Y9 3 SITE LOCATION to i �3 n T" E"_ 13 ° 0 �'d ° ©) 51 MAILM ADDRESS V T- J Ar #i V ,4 c �- C y Y_ 10-S' '7 PERSON INTERVIEWED -- _ -.. -- .- _- .... - - - -__ PCHD Complaint # ii Name & Relationship (i.e, owner,tenant, etc.) DATE c:7I 07 I4 V TYPE FACILITY %Z e . PROPOSED I1ISTALI J.1—"" °*— l3 IAA & �C'ti i PHA 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. wci�d t,004P 64-J, CoHcs -ur o ' Z lrl% .. w^ ..s... .. ....^}yv..T.s Fy .. --.—w :� -_ .. .. .e... �.- ... .. -..... «. a..o _.. .oy�..ti. ..�.. ....• '+ �w .. ... �oow <a _ cv�rs 7-- n . r Proposal approved %L hu"oo, Inspector's Signature & Proposal Disapproved Proposal aooroved with the following conditions: 1. Procurement of any Town permit, if applicable. 2. Submisgion 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 d. System description (e.g., 1250 gal. concrete septic tank, drywells surrounded by one foot + gravel). e. Installer's name and number. "a"�`� Date (e.g. house corners). three precast 6' diem. x 6' deep 3. System repair to be performed in accordance with the above proposal and conditions. I, as owner, or reported pagent of owner agree to the above conditions. SIGNA -J TITLE '6 k GATE `t MW: infinite (MD); Yellow (fin BE); Pink (AVPimnt)