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HomeMy WebLinkAbout4077DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 83.67 -1 -15 BOX 31 Is elm Is a i I all ■ 9 or I �114441, �' ra - .. 04077 t PUTNAM COUNTY HEALTH DEPARMNOIP DIVISION OF ENVIRONMENTAL HEALTH SERVICES 225- 3838/225- 3833/225 -3641 . -.rRVi iliit 'S17l�C'ala►:, L1rJCWir1L DYJ1J11' R^ AIR OWNER'S NAME ! y 1 A- e 1 !A, C to S S A N f I, ► PHONE SITE LOCATION � 2 w ► _ S'_ ZM# MAILING ADDRESS qty s7_z aoz.J- PERSON INTERVIEWED PCHD Complaint # Name & Relationship (i.e, owner,tenant, etc.) DATE TYPE FACILITY PROPOSED INSTALLER 0 WV OP , PHONE Proposal (include sketch locating all adjacent wells): NOTE: Repair must be in same location and of saine type as original sewage disposal system. Different location may require submittal of proposal from licensed professional engineer or registered architect. Proposal approved X_ Proposal Disapproved _ Inspector's Signature Title 91te roposal aDDroved 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 names. 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. (e.g.,house corners). three precast 6' diam. x 6' deep 3. System repair to be performed in accordance with the above proposal and conditions. I, as owner, or re7ted t of agree to the above conditions. SIGNATURE TITLE ©W Ki 4 i— DATE I zz� PIES: %Abe (P HD) i Yellow (Tam ED; Pink (Applicant)