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HomeMy WebLinkAbout4177DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 83.75 -1 -33 BOX 32 NNE '1 ;1 „ ,�. JJr ` IN r . IN' � -, '+� �. i or 04177 SITE LOCATION OWNER'S NAME _ MAILING ADDRESS PUTNAM COUNTY HEALTH DEPARTMENT DIVISION OF ENVIRONMENTAL HEALTH SERVICES PROPOSAL FOR SEWAGE DISPOSAL SYSTEM REPAIR OFFICIAL USE ONLY - d . 0g -0 d — F3 -- -/-3-? PHONE . -ZZY- —<9 b PERSON INTERVIEWED 61W !2I PCHD Complaint # Name & Relationslup I . o nc. DATE ?— Z 4 --©� TYPE FACILITY D S PROPOSED INSTALLER '' -1 —C PHONE ?y s ^�� /(, ADDRESS,n,� Z, ,6, lw IJ.�DV. REGISTRATION# ? 2 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. n�-7464- G 7— I, as owner;'o orted agent f o er agree to the conditions stated on this form. SIGNATIJ F TITLE ZPl• `✓ `{w� Proposal Proposal apwroved i e, following conditions: 1. Procurement of any Town permit, if applicable. 2. Submission of as built repair sketch in duplicate showing: a. Owner's name r—=.. DATE Z/ rZBuU 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. Proposalapproved__ Inspector's Signature & Title COPIES: White (PCHD); Yellow (Town BI); Pink (applicant) PC -RP 99ML 9. 3 ZATE