Loading...
HomeMy WebLinkAbout4134DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 83.74 -1 -24 BOX 32 04134 'F i :: yti ,� �� 7 1 ■ - 1 I�`1 ., ` u :k 1 16 Is '-- 0 IL t Lur 04134 PUTNAM COUNTY HEALTH DEPARTMENT -- -- - -- DIVISION OF ENVIRONMENTAL-HEALTH SERVICES . 0- 40 •' V PROPOSAL FOR SEWAGE DISPOSAL SYSTEM REPAIR FFICIAL USE ONLY SITE LOCATION i POr il- J) at lit TM# ?,3 , i Y f - .� S� OWNER'S NAME_ L k/%, t I' G 1-4 C PHONE 7J * '76 9 '6,y S�C MAILING ADDRESS f..: d X t✓ k_�e^ .re- W-S k I 1 1 t-1 i l O E3 7 PERSON INTERVIEWED PCHD Complaint # --Name & Relationship i.e., owner, tenant, etc. DATE 8 Z� 5— TYPE FACILITY PROPOSED STALLER kt/ 4-0 ' ��41 �- PHONE 0`0 S .76 -d S'9 . ADDRESS P off— ©4 ���� �� _ 71A , i o r25REGISTRATION# , � 7� � � � 7 C �� 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. 1 der -,vraE 5' — -74" (-- A\-� 4o 4 e- A fl- 04(g_ 4 0 (IL f3 3D 12 sc,+��C,��z ND C�Co_ see I, as owner, o reported went_ of owner agree to the conditions stated on this form. SIGNA TITLE A&rety r Proposal approved with the following conditions: 1 Procurement of any Town permit, if applicable. Submission of as built repair sketch in duplicate showing: a. Owner's name DATE g �� t� 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' diam. X 6' deep e. Installers' name and number. 3. System repair to be pe ed in accordance with the above proposal and conditions. Prop9SW,approved lnsp tor's Signature &Title 0�1 k�t OPIES: White (PCHD); Yellow (Town BI); Pink (applicant) PC -RP 99ML DATE f ro s , .... c .. a � .. . �_ .�„� .p"' .0 r*• � : -'• .�.A� . �», 3P.` (ef.5..a•:.. ?, �`� .._.. c -.i .. � - :Sv-.._ -r. ��;� i� - C'� � �: � � '�- ._. _ rz e- : C 49n4.,L le S � LrL$K fa %AJ 4 4X- ,a i _ w O V C4 1040 [S -'3 T- ,Ss c1 - -r�rz �2 r `7 P7PO4- IV, A,s. q1OS- AP 13 A 3 13 TJ 3 3o 9 0 19 P,,Cg tZ- 0 4Z C L (Er \ )/a 4-4 u6` c4f?-46 g��J pc- 02 0. S 13 3 (3 & Pvc 7-T 33o 6gt- Olzy wv--Lc. c c I IL IY