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HomeMy WebLinkAbout4191DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 83.80 -1 -18 BOX 32 04191 y a A- �,L r , kw 161 • r y �r 04191 PUTNAM COUNTY HEALTH DEPARTMENT DIVISION OF ENVIRONMENTAL HEALTH SERVICES OFFICIAL USE ONLY i-13' -O's- SITE LOCATION 3 / 7A4V4 ETs',r 7-Z e�-0 TM# 3, *n -- / —I ao OWNER'S NAME K v-fa °r F le £ 1% 'T A--f PHONE 9l Y XV V 3 6 o MAILING ADDRESS L.H- K'9 Tf- 9- K f k i t I / (9 -'Si- 7 y PERSON INTERVIEWED PCHD Complaint # Name & Relationship i.e., owner, tenant, etc. DATE nr? 30 0 PROPOSED ST,ALLER ;q & csc ADDRESS ,mot o% is TYPE FACILITY 1<-fS - a~a RAGce,1- PHONE X tl� S2 _ n�o Uc.- r-LO. C 1: d•.l `i f �!` REGISTRATION# PC / 8' 0 0 (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. ® we LCD eC,42 ex Acaw I V OT-7t9 as- owner;. aa'1_ r—i4s4. E ys-E d-af owner °agree to *lie °conditions stated on'thisyform: TITLE 46. <'ou "ir— DATE ,� /0-S, 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 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 ormed in accordance with the above proposal and conditions. Proposal approved pector's Signature & Title COPIES: White (PCHD); Yellow (Town BI); Pink (applicant) PC -RP 99NE DATE HOWARD GRAGERT :. ...: __ .296.05LE1WANA LACE RD: :.._ iP.JJTNAM VALLEY,_.NY 10; 79- 2400 . Ole h Mace Uf//-,o CAL C y tw G f2ZRC CC,, 41 U.