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HomeMy WebLinkAbout4712DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 91.25 -1-44 BOX 35 ME W, r 4, �r '- 'q�k- 11 1 NN u - 04712 P A' j' ., •. � vsTr.. 21 PU!'NAM COUNTY HEALTH DEPARTMENT DIVISIONT OF ENVIRONMENTAL HEALTH SERVICESn (� PROPOSAL FOR SEWAGE DISPOSAL SYSTEM REPAIR :: owNER's NAME t-2 V 1�,6,e �� 10 PHONE ,5�2 SITE LOWION ` v1 O hAl SnAJ :ST L't P-,-,�S C.;, u. m# 91�i7.. MAILING ADORES$ S l'YI Ci_S f-t �, y V P 1 ( 316 6 05f Y Z � PERSON INTERVIEWED PCHD Complaint # Name & Relationship (i.e, owner,tenant, etc.) DATE v S 1 TYPE FACILITY 5 PROPOSED INSTALLER hp- 2.o t,J ftC- A v p j , h 15� . -Z 1,-C • PHONE "' I L L- a0 D REGISTRATION # )•Z .. 4-1 404/ 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. p�s rrC Propcwf7 i46u ♦ wel Yv Proposal approved / / Proposal Disapproved ' pip f r s Signature & Title Date cate showing: a. Owner's name. b. Site Street Name, Town and Tax Map number. c. Location of installed camponents 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. (e.g. ,house corners). three precast 6' diem. x 6' deep 3. System repair to be performed in accordance with the above proposal and conditions. I, as owner, or reported agent of owner a ree to the above Lnd7itions. TITLE PAS: Wifbe MV; Yellow (nth EI); Pink (Appticant) 4 11 AV I ar I ar (vs I I I 115040 1 GI I I I 60/i.0r 0 as 1 1 1 1 0I Ie0.I9 1I1 x I4z.0ovs4s o9 / /1a SLO /sr 3e 38 - 1 y 55 1 1 35 All 1 34 ° o 1� I /1 w r �fiti F 9 33 1 i 1120.6 29.63 11150.541 1 I 1 I 1 I 1 I I I I 1 9 Go.co I 118,95 I ^; I 1 I I 40.20 , Ipe1 I 2a{I 60.34 � � � � U � STREET , - -- -- - -- -- 120.62 1 I If0.u3 1 t �s' 16 f j. i 1140.021 1 1 I I20.54 1 100.57 I I 1 1 I 15_.13 4s.i! 1 I 1 1 I I 1 146 r. 1 I 1 45 ' qa -' ; q3 I I t 1. 1 4 1 I n m I I 1 1 I I 1 I 1 421 f 1 1 I I I 1 I 1 4T t 1 1. ( I ..l I 1 tw I I I 1. . I 1 m I 1 1 I: I 1. 1 1 481 m ..I I.. 1 1 ;� 1 I'rl I I 1 1 I 1 1 49 I I 1 P 1 1 I R 1 I P I m 1 ei ��1 /r I I io 1 is I o 1 ti SP I I I 1 -! 1- I I 1 I I 1 I I I 1 rt I ri I i I sr 1 re. 1 1 1Go.00aj' 1 1ImumI I I- I I rt I ri 509 6.09 I 1 116 1 r., {toss a 80.37 Z I 1 I I I r2z?z 1 1/ ?'• I p I I I {p046 I ( /s9 L7S /Sr 1 /% I I /N IV /3Y //s 101.E 100.46 IBO.Bl I /60 1 ( /'u 1 I I I 1 1 /is I 44 I t I /SS I /si /� I I 1 1 59 1 I 6p I i /a r l 10546 I I /r1 I /n /m 1 /S9 I /SF /Si 1 /SS 1 1 I 1 +.: 1 i 581 I I- I 1 1. 1 I 1 I I 1 al 5T I I I D� ' I I 1 1 I 1 I' 1 I 1 i 1 1 - 1 I 1 � 1 I I I I I 1 I - - I 1 55 I 1 56 I 1 I 1 1 1. � I 1 I I I �•. 1 1 I I I I I 1 I I I 1. 1 1- � :., I ( I I 1 1 I I 1 I I 1 1 1 I t 1' I I 1 I 130so I I L 114D4o L {� 30.05 S IOO.l6 TRE t ^ N 1 80.31 I I I 1 I 190.19 +0 +9 ET !V( SOZe I 1 1 I I I u. a 1160.74 1 4o.1e 60.ze 140.{5 1 I 1 I I 1 1 I I 661 I I 651 I 64 1 1 I 1 I I 1 69 F 681 1 1 m 1 1 e 1,. 1 63 1 1 1 I 1 70 j 1 I 1% : I i I 1 e I• I 1 - I I -_ I- I I 162 1 172 I 71 I 1 1 I. s :1 73 m I I a l, I 1 I 1 a 1 I I I I is N I rs I ss 1 rr .e I rr I o ii lit Nis 1 I I - k P1 I Ps Al I n I 1' 1 I no_o7 1 eo.a 1 1 1 1 1 it 11w 1 it i /6 N /J I /Y 1 1 1 X6.06 60.061 J- -r 40.C2 140.02 /s 1 1 • I 40.04 {00.30 60.03 60.03 I 1 I I I o.oz 4 t,, I 160.20 I 1 I +0.74 e1, +5 6axt 40.12 z4o.ze I 9 I 1 I /�, 1 //t /u I //0 1 /os /a+ 1 /M '1 I Ic0.39 1 i I I /is 1 mo 'i /r /is /a 1. /os I /or /a. I /as' /ar x 1 I I /n /1s 1 /n /PSI /PS /Pi 1 /PS 1 /11 ai /m I 1 Ij us 1 I I I I 1 ( I I 1 1 1 /a7 I yy 11 0 (IIl /rr I /St I /ri 1 /ra 1 1 1 1 I I I 1 I I 791 I I 1 i I I 1 1 I 77 1 I 1 1 1 I I 1 781 1 I 1 I 1 I I 1 o I 1 _ I BO 1 I o 182 I 4 S ��: I I I I I I I 1 t •��' ,r�T�yi -, 1 1 1 1 1 I I I I 1 i I I i; • I I I I I I 1 1 1 I 1 <; : 1100.24- - 4.051