Loading...
HomeMy WebLinkAbout4150DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 83.74 -2 -22 BOX 32 ILI r 0 � T ' �'L : j �� ' 7 j I ` L F ` 04150 PUTNAM COUNTY HEALTH DEPARTMENT DIVISION OF ENVIRONMENTAL HEALTH SERVICES . .: •.. t:.. ;; .rr-c;;-�_: �..•., ..a.na:_ 5. .1 .. �. :.. -r'... ".-. ... �,..._.o-'t3E.. � -. �'.• .. -. �b.r � e_... `. R.:..�- yr u,+a ,�.:b';:.:� ..e '�vr -`.. PROPOSAL FOR SEWAGE DISPOSAL SYSTEM REPAIR OFFICIAL USE ONLY SITE LOCATION �Q�. /�0,�/� / �S TM# OWNER'S NAME PHONE MAILING ADDRESS 23 V&-61.e JS +� PERSON INTERVIEWED L A??0 ,14/-' S PCHD Complaint # ame & RelationsElp 5( Own! , nant, etc. DATE ®— Z - e / TYPE FACILITY /� PROPOSED INSTALLER_�� .oC. -L� PHONE VK 2�- ©,5-p n ADDRESS ,.,"g2 e,!J` REGISTRATION# ;;? Z- Proposal sa (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. s -e .d io v r I, as owner, or reported.agent of owner agrzq te. the e� . _tiops stat �I o ,slzissfo"*!xi .;:.. .....s . -� _.. SIGNA TITLE 0 -r, DATE Proposal approve with a 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 Inspector's Signature & Title COPIES: White (PCHD); Yellow (Town BI); Pink (applicant) PC -RP 99ML DATE