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HomeMy WebLinkAbout4369DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 84. -2 -23 BOX 33 04369 "'I ' ` . L rt_ INA ir: -,I ��� T �� 1 . �� .�. - . L6 . 04369 V PUTNAM COUN'T'Y HEALTH DEPA MEW DIVISION OF ENVIRONMENTAL HEALTH SERVICES PROPOSAL FOR SEWAGE DISPOSAL SYSTEM REPAIR OWMIS NAM PHONE r • SITE LOCATION i TVJAA4 (3 TO MAILING ADDRESS PERSON INTERVIEWED PCHD Complaint # Name & Relationship (i.e, owner,tenant, etc.) DATE //� � /� TYPE FACILITY PROPOSED INSTALLER o (-6- 1 /Z Ilf-A Q Y PHONE gqy' 7 _: C _28 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. To a(mt r e 2 m4 x S /1451,1+" p SaCT IN 4"6-W+111Fb F E p rA ®N, k 81;W f� cIr__S flzohs'• /Ir a R/6 iXUNGr1PN 6-P) ro • 11 . i i MA 0 r osa a r ed Proposal Disapproved O,Jss Inspector's Signature & Title 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 ccmponents 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, re or d agent of owner agree to the above conditions. 1 SIGNATURE TITLE 60,#J OATS 4Pg.1"-: Hhibe (PAD); YeUc w Mimi HO; Pink (Applicant) • r la 'w �?(� ®Pa >k "� �-t�,•�S �' ®rte / SfF 7-C-({ e � AHKS S Fl-� YAW a pAi) oil/ ��e"i V 1� �a J III IV I/ perNI411\ z- Aw<s v4 y Ac, P Rl V� vIA)or r` �OfAD 55166)0�? � Opt, Ott .i 1 ff�-Icpx m 0, : • o � ®r0 AP of NFL .',r-pl'tL © R. l�1 TZ1� p rH4AA V4o4t-Z-F -) NX} �, e ACA 1- Zf--R S R I1 e� LL 5r qto---�m \0 Aft-. A- ff 14 69'7 j 1 A 714 W n �-Z. I�P 8 �7f