Loading...
HomeMy WebLinkAbout4135DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 83.74 -1 -28 BOX 32 r en Y�' r .. ,�� •� 1#6 Lrr 04135 PUTNAM COUNTY HEALTH DEPARIMENT DIVISION OF ENVIRONMENmL HEALTH SERVICES `PROPOSAL FOR SEA DISPOSAL SYSTEM REPAIR OWNER'S NAME SITE LOCATIOIA MAILING ADDRE PHONE TM #6C -4 , I!} -I - IS PERSON INTERVIEWED PCFID Complaint # Name &Relationship (i.e, owner, tenant, etc.) DATE TYPE FACILITY PROPOSED INSTALLER 0 0 PHONE REGISTRATION # 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. ZI i s l d`! .gip C aJ71 C) a 2. 3. 's Siqnature & tle Proposal Disapproved with the following conditions: Procurement of any Town permit, if applicable. 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 canponents 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. -1) f-16 Date (e.g.,house corners). three precast 6' diem. x 6' deep System repair to be performed in accordance with the above proposal and conditions. as owner, or reported agent of owner agree to the above conditions. ATURE ' ` ., / TITLE cl- DATE f 9 -tube (PAD); Yellcw (fin EI); Pink (Aplic mt) 0 PUTNAM COUNTY HEALTH DEPARTMENT DIVISION OF ENVIRONMENTAL HEALTH SERVICES PROPOSAL FOR SEWAGE DISPOSAL SYSTEM REPAIR SITE LOCATION /C� PO ,.J T 17/L /V,9 OWNER'S NAME v d t'A— PHONE # ?ry' MAILING ADDRESS ; �'L:S (� V /._,,� V,-Ur ' � APPLICANT Name & Relationship (i.e., owner, tenant, contractor) DATE AA10106 FACILITY TYPE �r!'�j/ /e f �'%� PCHD COMPLAINT # X49 P��%$�(o /i..✓ PHONE # PROPOSED INSTALLER L�C,� L � j ADDRESS 3 � --�L 4W �,�,�a REGISTRATION /LICENSE # PC 303 -7-ig Proposal (include a separate sketch locating the house, property lines, all adjacent wells within 200 feet of repair and the location of existing and proposed trenches) NOTE: Repair must be in same location and of same type as original sewage disposal system. Different location and proposed pump systems will require submittal of proposal from licensed professional I, as o r, or r orted agent 9f owner agree to the conditions stated on this form SIGNATURE TITLE S DATE -'A t/o 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 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, etc.) e. Installers' name and phone number 3. System repair to be performed in accordance with the above proposal and conditions Pr posal Approved Proposal Denied E & JI spector's Signature & Title Date COPIES: White (PCHD); Yellow (Town 131); Pink (Installer), Orange (Applicant) PC -RP 99ML Rev. 8/05 v Ilao rt- I L ti ` is c` 1 ` a; Local Guy Plumbing / Drain Services Inc. 3 Finch Lane Lake Peekskill, N.Y. 10537 Tel: (845) 526 -2471 P e- 3 o3-7. Iq OC ® C —rA NIC ,,Vkr- � , (! 7AAV- wrl-r 0 _ 0 y ` 7" ��x O 19 IV 7`` Cef nc �4-[ Local Guy Plumbing / Drain Services, Inc. 3 Finch Lane Lake Peekskill, N.Y. 10537 Tel: (845) 526.2471 P C o3-7. if -r A Nix ,elf r- 7,snk- wrl,*,t' 5 ,j,vira-.,) 6 -3 x C 01V I C -)S` a,, 4. 1 Ott-, QA R b psi V-10y( n, .11leA 10 P©r,v -r fe,�"`' 7