Loading...
HomeMy WebLinkAbout4579DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 85.06 -1 -12 BOX 34 ZIP IN 0 me Ir IN Elm I N I' ' 1 it 1� !. I ■ F1 ■ 04579 PUTNAM COUNTY HEALTH DEPARTMENT DIVISION OF ENVIRONMERrAL- HEALTH..- SFR<7IC ES o PROPOSAL FOR SEWAGE DISPOSAL SYSTEM REPAIR OWNER'S NAME G C'.- ©r . 4 11V - � ,- Jq y r PHONE C 41) 57-9j c ,? SITE LOCATION ��f ' ' _ /,41,0 RV, - ,Ir2 f 71 g cj . /— / Z, MAILING ADDRESS bQ �i. n� 2 ©_ S ! % ✓` i S .� �r sr P _ O �G%�tio -7 Leo 1/1?y PERSON INTERVIEWED PCHD Complaint # Name & Relationship (i.e, owner,tenant, etc.) DATE TYPE FACILITY PROPOSED INSTALLER {& J1 %f f- - vL.0 PHONE tqT-`Z rr',S-0 (0 REGISTRATION # PC- 33 Z t-16 R ctc4sha r (aw 0 MCI- k6 )o at, -. 1V ' � ' Ca J`�(/ 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. -t P?,r7"q—`/ ( � / -2 �— .P (/ 1Z, C-o 41T coo r,,T It v,� - — Proposal approved s Signature & Title Proposal Disapproved romsal 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 d. System description (e.g., 1250 gal. concrete septic tank, drywells surrounded by one foot + gravel). e. Installer's name and number. dZ, Daa (e.g.,house corners). three precast 6' diam. x 6' deep 3. System repair to be performed in accordance with the above proposal and conditions. I, as owner, or r1eported agent of owner agree to the above conditions. SIGNATURE -" ' j,:� TITLE a'D L V A L1ATE 4-- Z Y 1N PIES: Wdte (PAD); Yel1cw (Tom ELI); Pink (Appliamt) Nou<3e- .� 41 1000 V. coneak- I lo A 4o Tun &Orl b)X yonr,eowner; C -�wrcx RroA-o 0 A4,Do.so(fs PL'tinarn Vou-ejl 10579-'Ot'15 eel 35 NAMF:P11TNAM miNTY nFPAPTMFNT np Dlssmued 10� bllcl �- HEKLA CONST., INC, 245 Road MAHOPAC. NEWBucksh011ow YORK 10541 JAN-3-2002 THU 13:59 TEL:e45-278 -7921 P- 1 JAN 3 '02 13:48 A a PAGE. 001 1��azj� Am .-r �, Cauetat4or-5 1 lcoo qak. Concatz oG ,ia tk. J lo' 4-an A 4o .Twi&On bix �junclion a-j( �brnee�u�ner ; A4 -DOso(is 7.an2 R,t� � v", N� ()6 ' �9 -��� in-q4m m jc�3l1 c I NI:KUA CONST INC. 245 8vckshollow Road MAHOPAC. NEW YORK 10541 PC, 33 . 845- &a2 -6-ab )k* TOT41 PACT . CIS 1 iIc:lc JAN -3 -2002 THU 14:01 TEL:845 -278 -7921 NAME:PUTNAM COUNTY nPPAPTMFNT nF P 1 FAAl 43 icoc 0. concm-te- *c, -irtxk- 110' aLnc-hoo f-jorae-ownu " 6wro y-, Fo-�ro,P-L+o a�} �osoris �n2 io?9,4,5 Tn s�k�ll ec! �a)3 i �e i J��, HIEKLA CONST., INC. 246 Buckshollow Road - MAHOPAC, NEW YORK 10541