HomeMy WebLinkAbout4000DOCUMENT CONVERSION SERVICES PROVIDED BY
IMAGING & MICROFILM ACCESS, INC.
www.scanyourdocs.com
631- 589 -8100
83.64 -1 -40
BOX 31
NNj
'
T ;�
or
T
I
9. No
■ ;
go
1
�i
�
�
`
;
AN
■'
J,
�
'r
,'';
No
INN
SITE IDCATION
R_a�a
PUTNAM COUNTY HEALTH DEPARMMENP r'
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
. «. ..: N: .. .. _...�,... ..(".'�....C:• .. .. :'t:. . .... ..,.. .. .: .. .. - - .. ..: 4- .. ,'mot= .'e...�. .. ... ....: R.:.�'
PROPOSAL FOR SEDGE DISPOSAL SYSTEM REPAIR ~~
PHONE Sa J- - u o / �
TO
MAILING ADDRESS 93 J- A / R RO AZ ,41-,91r /',E E /l15X J t c.. NV 161,39
PERSON INTERVIEWED PCHD Coglaint # �-/ 6
DATE�I`� L4 TYPE &Relationship (i.e, owner, tenant, etc.) �
TYPE FACILITY
PROPOSED INSTALLER ..1 ti y�/�E Z E ,L .0 fj PHONE
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.
0 C6
roposal roved Proposal Disapproved
is SPAture & Title Di
N c, G ( v r e-e
L-' .4JU4 r3 /L a..�
roposal approved with the following conditions:
1. Procurement of any Town permit, if applicable.
J
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' 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 of owner agree to the above conditions.
SIGNATURE TITLE 'S--- DATE �� 9
]PIES: [mute (P(M); YeUcw (Tam EI); Pink QaLiamt)
,4
s:
.. - F r-�.1 ,t icy ��,�,— •�• - •'f."''p�l! - r:�!�•' �._�.�•�" ... •...R..'r.... /-.�4'.�� "+ � `�`� — :;jc- .ri,:: r� _ _�. 'e:::. ^o �� • ..."`.• u
.- . e „ t . c .::� , ; •. C� , .G' a— ..cam:. �,,,.`�••T ." •'_ .
NE
N:
ev
IL
a''`t`ay�`�t' _.� 14/4+•, e' .' ., I`;� \ \�.. ,�:�q �`i+•.:!' ,••I' _ ..
340
EM
Ilk
• •,.:'. ��': �I f? .!tf.i V � e�'' V � GANG .. � � ":"�y�' t�4a;;,i {��`•,t;' �:....
`� 'r�.�r•e. '+ 6i;.. w,� �7 , *.� C � �V�'Ib4, ..(a�si aC1Y�i�Yic.:�W 'G.,.— �.;w..+a�uw
.., .. .. ,.. t -. •- '` ��% � ... � F .�. _ . ��� .... ...,. 666 .� _ ..
0
• •�f�•�� � .r+i� lV; 14'�',�Z 111 r'1' 1'�.�o ii i� y. y. ' >i ��,. •'
�,'• ' 1. V; "'!;fir IY f�i�� f'L, � , � ®e � ;� i ;t
.,� .elr'•T3:�''�,.tvy.'S58.'. ";1r• A;rt. °yt�,,•i, I;? .. tr,4.. a
SURVEY
s9.E /.v4� OF PROPERTY SIT'
�_ �,��it�f /S.ES .ml�1�%t�.C/ f/•�.�,.�0�/ . "
°.Jv %.`! � S - J,�lOit�.0
� � �� � � � 1L+
TOWN OF PUTNAM VALLEY; i
e ,
r � �