HomeMy WebLinkAbout4219DOCUMENT CONVERSION SERVICES PROVIDED BY
IMAGING & MICROFILM ACCESS, INC.
www.scanyourdocs.com
631- 589 -8100
83.81 -1 -49
BOX 32
Loom
�1IN
Lb P-A,
04219
Pv"-ru 12 xt- -P
PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
PROPOSAL FOR SEWAGE DISPOSAL SYSTEM REPAIR
OFFICIAL USE ONLY
R I - -DI
SITE LOCATION CP I-A V R E L- P- (L TM# 9 3 , �? I I ` 7
OWNER'S NAME M«A(A L- d S H e) e ®g CZF-P,0+ i1iV4 l PHONE s� 3 4` Z
MAILING ADDRESS t A K e- i) a 2 KSK t C L I I q 'Zf-. t o :; a7 j
PERSON
DATE
VIEWED PCHD Complaint #
- Name Relationship (i.e., owner, tenant, etc. tl,,pp Z� Q j TYPE FACILITY J? f---S'
PROPOSED INSTALLER t--W WA-R.
e -3'
.PHONE 9'YS .4-2-4
ADDRESS.-!6 1X'C14v.JA,&A P-d, ��?K�r�t/�t � y, l�l �` REGISTRATION# (3
J 10.5
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.
_ h as-owner, ,or- eporte'd agent of.own_ er agree to the conditions= statpd.on-th s-forrn.
SIGNATURE TITLE #46 6
Proposal avnroved with the following conditions:
1. Procurement of any Town permit, if applicable.
2. Submission of as built repair sketch in duplicate showing:
DATE � 9'1.
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