Loading...
HomeMy WebLinkAbout4159DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyou rdocs.com 631- 589 -8100 83.74 -2 -40 BOX 32 Ll ♦ , V.- Om -r ,-L� , , so N. ..k i r , or I ,; 04159 p. PUTNAM COUNTY HEALTH DEPARTMENT DIVISION OF ENVIRONMENTAL HEALTH SERVICES PROPOSAL FOR SEWAGE DISPOSAL SYSTEM REPAIR OFFICIAL USE ONLY �P/ l� - i�Y��° SITE LOCATION 3Q 9 KG x-- G rP ��/ �S i �� TM# 1-&2 . J -0e— U OWNER'S NAMES Al 2 ,! & " PHONE 4t 1 �' , °p - ? 991 MAILING ADDRESS d A? 1>t._ lraii Jay e'�� �— 3 7 PERSON INTERVIEWED -'�A-4 26 :Z 4 a PCHD Complaint # ame & Kelationslup i.e , owner. tenant, etc. — DATE TYPE FACILITY of PROPOSED INSTALLER ff ay � ���i �6',,J PHONE q' Z - j g :a3 ADDRESS 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. Boa- l I; o•. ;ter, or -rep r~ed•agent of t weer agr�:E' t0`the-Co�iditions -stated Orftliis foma. SIGNATURE ! TITLES/ DATE Proposal 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 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. approved, s Signature & Title 1+,PK 6 /-:�- 7 t10 J--- DATE White (PCHD); Yellow (Town BI); Pink (applicant) PC -RP 99NE JUN-15-2005 09:49 AN GAVIN CONSTRUCTION 744 8163 P.01 N- JUN -17 -2005 FRI 09:44 TEL:845-278-7921 tiAME:PUTNAM COUNTY DEPARTMENT OF P. 1 JUN -15 -2005 09:50 AM GAVIN CONSTRUCTION 744 8163 P.02 e ?0,c�o, ............. .. - ` J 0,;\ Itop _ -- ... ©C-- cam_ � Il.._� . ......... . JUN -17 -2005 FRI 09:44 TEL:845 -278 -7921 �IAME:PI_ITNAM COUNTY DEPARTMENT OF P. 2 "24 Vr l ql