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HomeMy WebLinkAbout4387DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 84. -2 -51 BOX 33 1 1 INS IA% I J. ' Ir , so I NIN r�T-I me ,j. I� IN X. 1 04387 1 - Ir , so I NIN r�T-I me ,j. X. 04387 PUTINAM COUNTY HEALTH DEPARTMENT DIVISION OF ENVIRONMENTAL HEALTH SERVICES Wl MUD OFFICIAL USE ONLY SITE LOCATION Ro'se V TM# OWNER'S NAME - o r r.; m t PHONE MAILING ADDRESS 90-S-e-4 -Vad l e4-2 ANr PERSON INTERVIEWED (,d rr� a✓�-�, �.t ,r PCHD Complaint #, Name & Relationship (i.e., owner, tenant, etc. WMW TYPE FACILITY J PROPOSED INSTALLER 4-10 u) ,-►� G r �r'�' PHONE `-� �j c 6 a (?I S ADDRESS a6 S (OL�i-'-a.wavici, Lam.lee- 0( �(�REGISTRATION# 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 prop %,�al from licensed professional engineer or registered architect. ob v -,:i rAxP h-- mi-6Ns V ce l o q S,)e1Sv1✓1q 4viv-- L o c t-b C/2, I AJ I, as owner,,9 reported agent of owrief'agree to'the conditions stated onthis forfri._. SIGNA TITLE ©L.e� &.Q 2 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 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 7/Z G /o / DATE NOW OR CHAD"VICI< P05,5-r 5 fo 0 cRoss 'j 65-4 '36 T, u 4j 1. v k Lo 0 AR.E.A. .45 Ac. k a M "7'0,q Y HO use 93' 'c /250 .94 411 1 I'v 45 •pv L- CROSS CROSS QV 1 vow OR 'wof?A'14:R Y ✓ RUTI-1 coqrirleo TH/4r THIS SURV-C)' WAS PRC1lAl?jrD IN ACCORDANCE WITH` THE C.Y15r1A1C; CODE OF PRAC-r1c:.E FOR 4.AAID AS A4;POPr,6D 0)' THE. NEW )'OHK S*rArE A.SSOCIA17-10AI OF ; OFE-S-5'OAJ,'A.L• .LAND .5URV6.ko V"5 SURVEY OF PROPERTY FOR KENNETH D. PATRICIA L. .."URVEYErj! MARCH 24, /979 3ARRETT BARRETT SITUATE IN THE JOHN SALVAT013E ROMEO TOWN OF PUTNAM. VALLEY I 1,1017THRIDGE FWAD PuTr4AM COUNT ,wihwi-o 6— .'Y EKK PESILL. N.Y '.0" 16,W .4y 9 nid ..p NEW YORK ,":6. 7h. 1w.' dl ... NYS Lit% 140 Z7U-1t;A- X 30 t�- t