HomeMy WebLinkAbout4263DOCUMENT CONVERSION SERVICES PROVIDED BY
IMAGING & MICROFILM ACCESS, INC.
www.scanyourdocs.com
631- 589 -8100
83.82 -2 -21
BOX 32
04263
J
�+
,
I
1
.
,I;
04263
OWNER'S NAME
W
PUTNAM COUNTY HEALTH DEPAR24ENT r
DIVISION OF ENVIRONMENTAL HEALTH SERVICES II
225- 3838/225- 3833/225- 3.641..
�PROPOSA'�; "SEWACE °`DISPOSAL 'EY'STEK REPAIit`
CARS
SITE LOCATION 4EW ITT SIREE7T �A)4 {peel <.$KILL
MAILING ADDRESS 10' GLE)1 MAR- GA-R'b US, kx 51
PERSON INTERVIEWED
DATE
ALL6-
PHONE ' e -4 3 I(A
TM# �Or5 a6 A
IV y, �oy'r9
PCHD Camplaint #
Name & Relationship (i.e, owner,tenant, etc.)
,1) TYPE FACILITY
PHONE
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 fram licensed professional engineer or
registered architect.
l k - 1 �, i. a `r 1 -1," cn . B r o e /^
Proposal Disapproved
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 corners).
d. System description (e.g., 1250 gal. concrete septic tank, three precast 6' diam. x 6' deep
drywells surrounded by one foot + gravel).
e. Installer's name and number.
3. System repair to be performed in accordance with the above proposal and conditions.
I, as owner or reported agent of owner agree to the above conditions.
_SIGNATURE
FM *doe (PGD); Yellc w (mar gD11PIrk (A A is nt)
TITLE
DATE
:4A
i 1
�P
i
y� -17
Z
o 'SAP
NCL'
2
o
'• P R
t4OLJ5 E
\ - 1
S7 +` O
0
.�� 15 Z4' �(O ✓
' •q ` I V