HomeMy WebLinkAbout4074DOCUMENT CONVERSION SERVICES PROVIDED BY
IMAGING & MICROFILM ACCESS, INC.
www.scanyourdocs.com
631- 589 -8100
83.67 -1 -12
BOX 31
04074
.,
NIN
I'll
All
.
IN
IN
IN
L
'
IN
� . .
.
,
04074
PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
V
OFFICIAL USE ONLY
(DATE E LOCATION l,� 6V ITT �' TM# R3. 1 ! Z
WNER'S NAME LA K � �ciH- � PHONE 5'7-e *III V
AILING ADDRESS. � pg.+ lcM �-C , 9� l L0 S-3 -7
RSON INTERVIEWED PCHD Complaint #
ame Relationship i.e., owner, tenant, etc.
!D 1 TYPE FACILITYOPOSED INSTALLER ,� �fLl� PHONE S�
ADDRESS �Zq6 It , GISTRATION# pC
V 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.
��`.. Heal- A k Y r,LATa A, 'b 1FX(5-7_1,q,6 tlr,o t.L r
I, as owner, Ar reported agent of owner agree to the conditions stated on this form.
SIGN 9 TITLE —A ��' DATE 0
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 performed in accordance with the above proposal and conditions.
Proposal approved �-
t
Inspector's Signature & Title
COPIES: White (PCHD); Yellow (Town BI); Pink (applicant)
PC -RP 99ML
DATE