HomeMy WebLinkAbout4260DOCUMENT CONVERSION SERVICES PROVIDED BY
IMAGING & MICROFILM ACCESS, INC.
www.scanyourdocs.com
631- 589 -8100
83.82 -1 -40
BOX 32
04260
1.
' km!
r T
.VL
r ,
'.
�
po
n.
04260
SITE LOCATION
OWNER'S NAM]
MAILING ADDR
PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
'; 1 1 I t
V/1
OFFICIAL USE ONLY
K3139-011
TPHONE�l`X__.�/
PERSON INTERVIEWED 6wno-r PCHD Complaint #
ame & Relationship i.e., owner, tenant, etc.
DATE TYPE FACILITY _6.e�
PROPOSED INSTALLER PHONE
ADDRESS J k �a GISTRATION#
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.
te
c
I; as owner, Sr reported agent'of owner agree to the conditions stated onntliis Toren. J %
SIGNA TITLE DATE �/ / 6
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.
Proposal approved
Inspector's -,Signature & Title
COPIES: White (PC> ID); Yellow (Town BI); Pink (applicant)
PC -RP 99NIL
1012.rl0V
DATE