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HomeMy WebLinkAbout4056DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 83.66 -2 -52 BOX 31 } L' ,'V f , al [in owl PUTNAM COUNTY HEALTH DEPARTMENT DIVISION OF ENVIRONMENTAL HEALTH SERVICES SITE LOCATION �, OWNER'S NAME —� k "rah Ik. MAILING ADDRESS f0 Ne>,t V OFFICIAL USE ONLY '06./ TM# $ &n 66 -- 2-- 5-2- PHONES 5-25 q;6 PERSON INTERVIEWED PCHD Complaint # Name & Relationship i.e., owner, tenant, etc. DATE TYPE FACILITY PROPOSED INSTALLER two -r`C cL� n, 0 L h S PHONEC�- 7 S O SS ADDRESS REGISTRATION# PL SG 0 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. L V C. X9 4-1 kAWC U.. � <l;„ v 4- -4- &e pL�� cz ck¢a..Yew . `arc- xlmn Vz- ots 6vl li- par jt:�Z 6 --iau. owner, or "reported agent of owner agree'to the conditions stated'on' this form. SIGNATURE ''' a2 l rTITLE DATE 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 comers). d. System description (e.g., 1250 gal. Concrete septic tank, three precast 6' diam. X 6' deep e. Installers' name and number. 3. System repair to be pe ed in accordance with the above proposal and conditions. PrDoosal approve sc- Inspector's Signature & Title C DA COPIES: White (PCHD); Yellow (Town BI); Pink (applicant) PC -RP 99ML le 4. k LSOACLF-d �b o t61 9 90 v ic�o�u.li ©� fu4x� 2Cll 1 3G I 'S 3 Ar�y l� 5 F,,Ki ski nb �/ s%e WL C�jd Wet( 1;( IN � 0