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HomeMy WebLinkAbout4045DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 83.66 -2 -15 BOX 31 I .�._ % hula PEI ly, ., r s . V r Z6 r . 1 i -.�' oi i r L ; y 6.2 04045 [1. -.1".*. b -; 1 T SAP- 1-99 THU 9:26 AM PUNA11 '-TY EITIV HEAL.H FAX NO. 10142787921 P. 2 • PMPX Comm Mal" DW10DW PFCFOSAL POR SEWRM DLSPCM SYSTEM F"AM CHM's MM Aw-v-&'10 paw SM Lx=0N M" M== ADMW 009 -r PM. COW-34k' nt # N= & PtelatiFnMl; (.e, 0WDWPt0=t' etc.) D= 'TYPE PAM MY -SLADss-A Pam= numum Aryv---�. 1pj� REGISTRATION # :P=pml (include sketch locating all adjacent Wz: Repair must be - in saw locative and cf Different location may require mit=ttal of poc registered architect. wells same type as original sm p disposdt system. rr opowl -fray liewund engineer Cr K le— a - VL CAL eate I . Y 15 C'4/- io /z!E- ;��y Z--7 — a=oved with the foil conditions: 1.'Pro=eWnt of -ar7 T06M permit, it applicame, 2.. O&W it ion of as built repair sketch in d4plicate dw0g: .a. om=lz um. 'b. Site street Name, Town and Tax Map number. c. Location of installed components,tied to two ftwd points (e.g. ,boot con=s). d. System description (e.g.? 1250 gal. concrete septic tanks three precast 41 diam. 3i 61 6W ftywells awrounded by cne foot + gravel) ..a. X�stallels oame and nwber. 3. System repair to, be performed in accordance, with the above proposal and conditions. I, as owner, or reported agent of owner agree to ; Wts (W); cellar Mm MY Plzk (AVU=*) the above oonditicas. Trim 7. S5F- 1-99 �F 9 :26 AY PUNA31 CM ENV THEALTH FAX NO. 19142787921 P. 2 CHMIS N*z 41av-&4' :rJ-_-1jA'5V'q pow S= W=CV L.-&,wa %%wo L_&V4 Qiey.-C=y_,jL1. MAMWM ADURM 17 -n-w_ 40 -,-P=. CaImplaint Nme Relationship 01-e, OvAr'Ptaint, etc.-) DA32 TM n=TTY '5LABLeAAge&4& PmP= memum Asyu& C;O(Pco REGISTRATION # proMsal (include sketch locating all adjacent wells): Wm.-. VapeLir must be in same location and of am type as original seta p Different location may require suknittal of propoal fr= licenimd yrofemd**1 engineer cr registered architect. C-C C <; PrCIP0811 approved DiMWCVQd a SignatIare 6 I ta Mfi IM=d Frith the full =Aitimss 1. S PM=Gmnt Of any Town perms t, - if amlicable. 2.. Submission of as built repair sketch in ftlicate aiming: a. Owhser's name. Site _street Nmj Town and Tax (dap ==bar. c. imtioft of installed =Vomts tied to two fixed pointe d. SystAm dw=iptiqn (e.g.# 1250 gal. concrete septic took, three precast 6 dian. 61 dmp drpdls s==undisd by one foot + gravel). ..a. Inataller I s (hme and tuber. 3. Syetsm repair to be perfamd in acmrdance with the above J. and =fttiom- it as owner, or reported agent of owner agree to the above cociditims. SIB TM DATA TM: *Ate aKM); YaUcw Mm IM) I Dirk Lk#imIz*j •• `CHAS. H. SELLS, INC. P.O. BOX 426,550 BEDFORD ROAD BEDFORD HILLS, NEW YORK 10507 TEL: (914),2414944 FAX. (81.4 .241- 6.733. _ 241-9194 w m,chashsells.com TO: wTgovt eaoA►;Ty WWI. 01 LETTER OF TRANSMITTAL DATE JOB NO. NO. DESCRIPTION 4 . 46e. v4r j�o, 1050 WE ARE SENDING YOU Attached [] Under separate cover via .: the following items: ❑ Shop Drawings ❑ 'Prints lans ❑ Samples ❑specifications ❑ Copy of Letter ❑ Change Order ❑ COPIES DATE NO. DESCRIPTION 1 10 'Zls 10 o$a d✓ S+a . s aw' t ZZ 44 StZA THESE ARE TRANSMITTED as checked below: 91-For Approval ❑ Approved as submitted ❑ Resubmit copies for approval --� -' For yc or use' "' "` " ' proved a's nofed �" ` -❑ submit copies for distribution* ❑ As requested ❑ Return for corrections ❑ Return ❑ For review and comment M ❑ FOR BIDS DUE REMARKS corrected prints 19 ❑ PRINTS RETURNED AFTER LOAN TO US COPY TO: SIGNED: T:IFORMS \Transmittal.doc 61" W1 lox A - TI. .0 1000 G-1 pla'slic 0 P,*,. r I . . & I 77 Ftij i� C1, Ip, tie 1 C6 PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH'SERVICES DESIGN DATA SHEET' - SUBSURFACE SEWAdE*..TREATMENT SYSTEM �Z2 tz; Owner Located at (Street) Tax,Map 93#Votlock- 1-/ Lot (indicate nearest, cross street),; Municipality v "SOILIPERCOLA' .16 Date of Pre.-soaking 2. Tests to be repeated at'same depth until approx'imaiely equal percolation rates are obtained at-each percolation, test hole. (i.e. s I min for 1-30 min/inch, -.q 2 min for 31-60 min/inch) All data-to:be submitted for review. Depth measurements to be made from top of hole.- Form DD-97 Design Professional's Seal pf NEIN.y��� N� FA S49 co F s may- rot, =<v 0 F,+ � fsPFOFSSI ©��'� �L�G1 SITE MAIL PERSON INTERVIEWED l 10 d 3 -17d 6 PAID Caaplaint # Name _ & Relationship (Z e, owner, tenant, etc.) _ _ (, DATE TYPE FACILITY _ _..,8 4ml- PROPOSED INSTAI.LM [� ',� ►aw H owne2 PHONE s,, y82 1-Y-13 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. d" Steitm wn-va P1ff-_ -A nkrt1 AUD TAU �m fU � b Proposal approved Pr sal Disappr Inspector's Signature & Title Da 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 canponents 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 drywel.ls surrounded by one foot '+ gravel) e. Installer's.name and number.. 3. System repair to.,ber£cficl in accordance with the above proposal and bonditions I, as agree to the above conditions. TITLE 0IVAMM y 23 79 SIGNATURE ,4 �.AwASGiiI� OMs: Vbite (Pam); Yel w�:( a � Li;: 'La pt1cant) A�cy/�eCf' LA 13,"M, WUM377 fU � b Proposal approved Pr sal Disappr Inspector's Signature & Title Da 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 canponents 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 drywel.ls surrounded by one foot '+ gravel) e. Installer's.name and number.. 3. System repair to.,ber£cficl in accordance with the above proposal and bonditions I, as agree to the above conditions. TITLE 0IVAMM y 23 79 SIGNATURE ,4 �.AwASGiiI� OMs: Vbite (Pam); Yel w�:( a � Li;: 'La pt1cant) A�cy/�eCf' I F. 0 21D, •: • X 0A I L 1:)4 V% a A • lao 1 1 a A_a~&_f I M1— 14 71 '2AA -9 'T oP�sm z MACcA 14 LIANDS2AP. I FHCNE Cg 14)141 `11 (12 REGISTRATION # Proposal (include sketch locating all adjacent wells): NOM,: Repair must be in same location and of same type as original saa4ge disposal syst�p. Different location 'may require submittal of propo sal from licensed professional engineer or registered architect. � Ala) DP-YWeAA.. P%hp.A Prz i re L* the following conditions: L. Date 1. Procurewnt of any Town permito if applicable. 2. Submission of as built repair sketch in duplicate showing.* a. Owner's name. b. Site Street Nam, Town and Tax Map number. c. 1,ocation of installed components tied to two fixed points (e.g.sphouse corners). d. System description (e.g., 1250 gal. concrete septic tank,, three precast 61 dim. x 61 deep drywells surrounded by one foot I + gravel). e. Installer's naves and number. 3., System repair to be performed in accordance, with the above proposal and conditions. I,, as ownerg or r Of agree to the above conditions, = &UA40AA SIGPM M TJ CWM: Vbite MM YeUcw Mbn 91); Pink Gglicmit) PC-RP 97 PUTNAM COUNTY HEALTH DEPARTMENT /W DIVISION OF HEALTH SERVICES ..: ose.:i..ir �•e.- a.. '. -•'x: ...'y' .:v_. ...... y •. �i ..: v.'.,.t ��',iw 7.;' .;'w:�.:. `,:��. •.�'�..' •i.:..a... :ay° ....a ::':�:.' .•a:.::• PROPOSAL FOR SEDGEDISPO6AL SYSTEM REPAIR OWNER'S NAME '04 4-tic fTv R o c s 5 N At* VU 4 PHCNE SITE LOCATION 5, 1 [ActQ NA K Ot ! hQ e Y .� pq & 3.6 MAILING ADDRESS ,� vim- CT (Rea -C. r Kcc(c . N.'y • t Lo 2 3 � PERSON INTERVIEWED PM Crnnplaint # Mn- . e _ � . Name & Relationship U. e, owner tenant, etc.) - - � TYPE FACILSTY PROPOSED INSTALLER .i.4" a 4G -Ex-r PHA S-4(o —;LSV'S% REGISTRATION # 31? 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. 's Sicmature & Proposal Disapproved 'roposal 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 canponents 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, r reported agent of owner agree to the above conditions. SIGNATURE �r Ptr TITLE /�CQ CPM White (POD); Yellow (fin ffi); Pink (Aniiaent) GATE Q13/2 b PUTNAM. COUNT L DEPARTMENT OF HEALTH NO o 6 4 - . 8 -1 9 COMPLAINT OR.SERVICE REQUEST REC "T GWN P u 't n d'i►T V a i"1`e A .. , DA "rE' - '7 i 6 :Z y 8 TAKEN BY D K TELEPHONE CALL X IN PERSON LETTER CONFIDENTIAL REQUEST FROM Mrs. Lubin TELEPHONE (21 2) 352 -6543 ( work ) ADDRESS . ENVIRONMENTAL HEALTH: Home Sewage_ Rodents Refuse Public Water Food Service Migrant Camp - - Other. COMPLAINT OR REQUEST In Lake Peekskill - neighbors backyard has water resting.An the land ACTION TAKEN BY _ ��.4 DATE��(Y /�� FINDINGS ✓•a -u- ` © h s C vv t s c 0. K-L -✓-, -t lj .A,�eIA p° yJ-C CK2 K�11 '� -i��° -.i. G�+-F/ •. Imo/ L 0. %..0 . f Llo,�� Ownc� h, c vt,oti;� .2.oA4k Na p - FOLLOW UPI SPEC ION (s) .ZAM .:.. �� -"9 � -" tTNTJiNG - _ ��.4 iJ �6- i f <-f-i d 0. K-L PROBLEM ABA ED DATE o g� PERSON NOTIFIED�s.. Lam. 6 n ESTIMATED TOTAL MAN HOURS SPENT 3 77 " . d ,,, °•., a r, . , • Rr,COP:' OF �,.F,IO\ CON'El�'1 IEII�% • • . .. PUTNAM COUNTY DEPARTMENT OF HEALTH Division of Environmenal Health Services Facility: . S2, -L-6 4 Dr. Town: 'f Time: Date: 7 9 p Telephone # q -, 6� 2'Z-- � Caller's Name: mt -- Mr. Tar o 45 k� DISCUSSION: .174- 7-CA TU 4s 1s -�d A, S. �- S Z t,L D-. A Signed: Date: iz f7 � Rev. 6/97 a S] K PRISM INTERVIEWED. / I 0,:R 3 - 17O (_ PCHD Complaint -. # Name & Relationship (i.e, owner,tenant, etc.) DATE TYPE FACILITY -,Jhr �e1I+i /Y D PROPOSED INSTALLER � °( f 4 } kw 6V ow n ea PHONE s f, M 1-Y-13 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. K£ pipe, sTbK#t Proposal approved Inspector's Signature & Proposal approved with the tle LATAO F1 Pr sal tions: Dm f s° to Disappr 1. Procurement of any Town permit, if applicable. 2. Submission of as built repair sketch in duplicate showing: Da a. Owner's name. b. Site Street Name, Town and Tax Map number. c. Location of installed components tied to two fixed paints (e.g.,house corners). d. System description (e.g., 1250 gal. concrete septic tank, three precast 6' diam. x 61 deep drywells surrounded by one foot + gravel). e. Installer's name and number. 3. System repair to,,.be,-,1*r`f6rmed in accordance I, as ed °a t "of agree to SIGNATURE _.J 1 CP1ES: %Y►ite ( ); Ye11�iw:(' aiHi);_;�iiilc Valiamt) with the above proposal and conditions. the above conditions. TITLE ® J M41' �TE qL231 98' IVtAA COUNTY 'DEPARTMENT OF HEALTH omplaint N0:213-98-1 9 COMPLAINT OR SERVICE REQUEST RECOP TOWN P U T N A M VALLEY DATE 4/15/q8 REFERRED I TAKEN BY PM TELEPHONE -CALL X_ IN PERSON LETTER CONFIDENTIAL. REQUEST FROM Luhin TELEPHONE (�i -3 (Work #) ADDRESS .. .49 Lake Drive. Lake Peekskill ENVIRONMENTAL HEALTH: -Sewage Nui-sance x Public-Health Nuisance Chemical Emergency Individual Water Other COMPLAINT OR REQUEST Lake Peekskill septic leaking onto her property (ho . use left of cabin) LA ACTION TAKEN BY DATE y/Zozf W, FINDINGS -s eon L — -s 44,04 Ae_ io )-c- 10 Ir-, C' J o- -I�A 1 .12 r- k, d -)I d-� -enc g" � -k jr � s, fc 0 ypt" , k C_ t. S e, �o tLL V 8 z - 'z y 2.3 ]DATE 4z Z. 71 FINDINGS- h. a 574--e DATE FINDINGS. PROBLEM ABATEP DATE z PERSON NOTIFIED atle C, r L-4 51 do t-., ESTIMATED TOTAL MAN HOURS SPENT PC-CR RD G71 'V�`.i L'JJJY�/l fl0NE'C0N7V RSAl (5l�f` EUTNAM COUNTY DEPARTMENT OF HEALTH Division of Environmenal Health Services )Facility: 5z Town. Time: Y : 0 Date: Y Telephone # (-/ Z 2 y Z 3 Caller's Name: �as .lam % r s 11 (DISCUSSION: -C 'r --A 4 '.s SSTs ke- J,� -C u 4 tin d O r C, D C., W S fir- 4,3 � L, ' _- a 9 . < -e, S Signed: c � Date: y1Z9Y Rev. 6/97 OW SIT] MAI] PERSON INTERVIBM . l ! o a 3 ' 170 (o PCHD Canplaint # Name & Relationship (i.e, owner,tenant, etc.) L DATE TYPE FACILITY fe :UV m • 11 PROPOSED INSTALLER &E4 IRW 6H o W n e2 PHONE S 6 Y 8Z 1. 23 REGISTRATION # Praposal.(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. KS " fio' M wnea APP- 820iceO A up TAm x rrrs srap o . pipe. sTbKM WATfs� wm-> wwnr•nrb +rY Iv I `•ORS �' AR�A•y "PI Pe Wf5 RAl� b �?.. cHeckeo FbA Agour 46 �Vwn -W—M rNFAM I Proposal approved Inspector's Signature & Title - mom f ' A° i1 Disappr D�a 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 drywalls surrounded by one foot + gravel). e. Installer's name and number. 3. System repair to..be',:perfo�n�d in accordance with the above proposal and bonditions. I, as a t "'of' agree to the above conditions. SIGNATURE TITLE d o L231 / W IPI n Hhite (POtn); Yd4 �► (Tq� `BM1 ;:41j)k" (kplimnt) :'.: n:. ,,.,�o.".i`iw:� "r..�..�,...w..� �.�.::i' t ':b'.:'..:.. �.... �7`.'" YOY�i.. �l\ Hl��V` l��' �SJ ��YJL lI' iPV����KY�16A7�2' �4i1'V�..�.:n�'.:.�.:::.'.�� °u� .�..._.,;...,'.- •.,�.�:� ,.�_�1:.'�.-.: :. PUTNAM COUNTY DEPARTMENT OF HEALTH Division of Environmenal Health Services Facility: L e.- k-s— Town: P, V Time: y Date: Telephone # Caller's Name: DISCUSSION: e- a ss Signed: Date: 2 Rev. 6/97 40 Signed: Date: 2 Rev. 6/97 PUTNAM COUNTY DEPARTMENT OF HEALTH int 0633 -98 -19 COMPLAINT OR SERVICE REQUEST RE TO�iIN i naTCi `T c ej ' DATE /' (9/,90 REFERRED TO r TAKEN BY TELEPHONE .CALL__IL_ IN PERSON TTER CONFIDENTIAL. REQUEST FROM Jirt Foley TELEPHONE 526 -0942 ADDRESS 52 Lake Drive, Lake Peekskill 7- � -366 a ENyiRONMENTAL,HEALTH: Sewage Nuisance_ X_ _ Pub-lic Health Nuisance. Chemical Emergency Individual Water Other COMPLAINT OR REQUEST Complaintant is renting house from Charles Turofsky- septic leaking in backyard and going into Lake Peekskill. 9 /y�,� g{ �- �-1��� -�� ��. - 4441 -r 1s ACTION TAKEN BY Cd�I ! AbC L `' +�- DATE 6 FINDINGS a.j ,4,01t -k- $a i I *r, 1,e C, d t .1 y a o w y. /e 4c— he.a�• S'�.,.,� r,.�e Qs • d�s� s s TS -�. �f<...�.e Z L4 k� FOi,LO�i TJP 'IN PECTION 's) DATE 2 3 i� FINDINGS 2 s DATE Z FINDINGS ff reap da yr,,p .dy e — a , IN 519 g /Uo sw� � w t, ° 2 9 9 Al, 1 g A)a 5 v��CL wA K� ✓l o GN�-v PROBLEM ABATED / 0 / `l9 r r` /! I DATE PERSON NOTIFIED to PC -CR ESTIMATED TOTAL MAN HOURS SPENT 97 f.: I. Id PUTNAM COUNT:. DEP.A RT E r -3 'D ION OF ENVIRONMENTAL HEALTH SERVICES INITIAL INDIVIDUAL ADDITION i REPAIR FORM SECTION A.'. GENERAL INFORMATION Name of Project 5'Z I. ct L� D * � ° P• 'Mo. Mo �3 ,5 Z Year of Construction Size of Parcel SECTION B.. TOPOGRAPHY (Please check all appropriate boxes) 1. 011illy DRolling U slope OGentle slope nFlat' id 2. - OD/Llow Evidence of wetlands areas subject. to flooding , [Bodies of water, DDrainage ditches DRo c*k outcrops 3. Property lines evident? ; ❑ 4 4. ,Water courses exist_on, .or adjacent to parcel ?: 5. Existing individual wells within 200ft of the existing. SSTS? SECTION C. EXISTING SUBSURFACE SEWAGE TREATMENT: SYSTEM (SSTS)s ":;;: -, 1. Physical character of existing SSTS area. A. 7ILevel ' [,Gentle slope LJSteep slope B. : ❑Well drained Moderately well drained F i [Somewhat poorly drained OPoorly drained C. Area available for SSTS. (Primary. & Reserve) 4 0'E-xtremely limited ❑Somewhat.limited DAdequate 3 ft x ft 'j' i - to .Z-NSPE/'tTI + nNo evidence of failure Evidence of failure ®Evidence of seasonal failure r - - - - -- - - - - - - �1 �s- - - - - - - medicate North Gh Q _ 'HOUSE l tri . \ C7 T e� s K (1) Indicate location of SSTS { A. Size and type of septic tank' ' gallons Y+. ,w Metal OConcrete OPlasti"'- d_...._: B. Type of absorption—area 1. Fields ft : -. ' 2. Pits 3. Gallies ft. (2) Indicate setbacks, front street, backyard, and side yard dimensions .`. :..(3) Show.location of well - (4) Show location of driveway 5 Note physical features (steep slopes.. rock outcro . s , streams /wetlands) SECTION E. EXISTING LATE =SiJPfl'I.Y 4 CIPWS. ' COMMENTS: OWN SIT MAI PERSON INTERVIEWED . - _ i. - . . . l l . p -R. -3 ` /70 (o PCHD Canplaint # Name & Relationship (i.e, owner,tenant, etc.) L DATE TYPE FACILITY I� �Ith. PRoPosED n1smim 2,i jaw ow n e2 PHOM. s l Y 82 J-0-3 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. ��► K� n �UXJK WATEA PIPE 69oke-0 A013 T . x rrs srupfto . pPe. slbam -�- •• WHTG+t r n7 rrvmr•rvb �ry IV SFf T16 a 0 E 0_ J, 01 �!P. IdI t f��DA! "I n Proposal approved Inspector's Signature & 2. lan- r 1c{Jnl ) V w Pr sal Disappr A b conditions: ��w•.u. u....a•a. va cu al ay...• rc,.aa•.a w, as ,at+�iawuic.. 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 canponents 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'-;per£btmed in accordance with the above proposal and bonditions. I, as t a t "of agree to the above conditions. SIGNATURE ` TITLE d e 23 I r AoA4 1-01AsCAp6. PIES: W-dbe (FU n); Ye];lAw ; c a ) ;: � nit (Applirar►t) A '/i �" INV AM M mom Proposal approved Inspector's Signature & 2. lan- r 1c{Jnl ) V w Pr sal Disappr A b conditions: ��w•.u. u....a•a. va cu al ay...• rc,.aa•.a w, as ,at+�iawuic.. 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 canponents 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'-;per£btmed in accordance with the above proposal and bonditions. I, as t a t "of agree to the above conditions. SIGNATURE ` TITLE d e 23 I r AoA4 1-01AsCAp6. PIES: W-dbe (FU n); Ye];lAw ; c a ) ;: � nit (Applirar►t) A '/i �" PUI'NAM OOUNTY HEALTH DEPARDOIP .D..SION - lE' -EWI � �'�'� PROPOSAL FUR S D&Z DISPOSAL SYSTEM REPAIR mm's NAME 1D IAWS iURo y PHWE 174e y 92,24 7.2 SITE LOCATION ' SI `LAk . 1 aZ TO MAILING ADDRESS L AK6 ftlr,64U., PERSON INTERVIENM C IJ AALEE TU,VOrr-.S 1 bWN JZS REP PCHD Catplaint # Name & ationship (i.e; owner,tenant, etc.) LATE 1U TYPE F'XILITY PROPOSED DETAU M MACC414 LAKOi CW 1 N(o PHONE C9 141141, It t 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. A NSW MY WeA.L. i� is 1 WF1,Lr2*rtW Big '. e. •;�: pal M?T Proposal approved — Proposal Di�� saoved s Signature & Title Date 'roposal 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. eoncrete.septic tank, three precast 6' diam. x 61 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 ed a of ow agree to the above conditions. SIGNATURE TITLE DATE MMES: hhite MV; Yetloow (Tkn BS)'; Pink LkpUamt)