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HomeMy WebLinkAbout4128DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 83.74 -1 -8 BOX 32 04128 7..ra P 296 0 ci ©raa wens Nd. PUTNAM COUN'T'Y HEALTH DEPARTMENT uftm Yaney. NY 10679 DIVISION OF ENVIRONMENEAL HEALTH SERVICES PROPOSAL FOR SEWAGE DISPOSAL SYSTEM REPAIR OWNER'S NAME hA R, d- tnw by T 2.. PHONE Y c I O SITE LOCATION PO , .�.t', r TO �3, 7Y -" MAILING ADDRESS L'> A kF- 9 g �7 gsk PERSON INTERVIEWED PM Complaint # Name & Relationship (i.e, owner,tenant, etc.) DATE /'L TYPE FACILITY PROPOSED INSTALLER L,v,4 (;A41.6 F Rte'" Iv - Qv (-c c 4- l PHA !;:P G 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 fron licensed professional engineer or registered architect. tom. )G rSr'rk'G F1W1r e -t)-F-'TF (2''e 1 111 Proposal apgiW K Proposal Disapproved Inspector's Signatuke & 2 e '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. 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 performed in accordance with the above proposal and conditions. I, as owner,�or reported agent of owner agree to the above conditions. SIGNATURE «" TITLE 14eC4k417" OATS [PIS: White (PAD); YeUc w (yah SI); Pink U pliamt)