HomeMy WebLinkAbout4723DOCUMENT CONVERSION SERVICES PROVIDED BY
IMAGING & MICROFILM ACCESS, INC.
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BOX 35
04723
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PUTNAM COUNTY HEALTH DEPARTMENT
'DIVISION OF ENVIRONMENTAL HEALTH SERVICES
"A 225 -0310.
PROPOSAL FOR:- StWAGE' DISPOSAL SYST.DUREPAIR - <- - }
OWNER'S NAME _� c r Pvt G • n c. -9, V-- PHONE 9 14 - �-Z 8 -28'77
SITE LOCATION
MAILUaG ADDRESS k5 k; r AJ
PERSON INTERVIEWED PCHD Complaint #
Name & Relationship (i.e, owner,tenant, etc.)
DATE reb 1.4 89-- TYPE FACILITY
PROPOSED INSTALLER 5e I PHONE 6'2, d -.18 ?'�
Pro (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.
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Proposal approved� Proposal Disapproved
Inspector's Signature &
Proposal awroved 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.
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c. Location of installed canponents 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 . ��iQ f �'-e •,— o �c,,,�� -�c TITLE oW hNp DATE Li u°
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C"I IN hVe 0&,tA44Af M&WrY tli'kirl Oftlrt
AS AUP h'F AMS ON 04Y, 04 1919.
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CERTIFICATIONS INDICATED HEREON SIGNIFY THIS
I-'SURVEY WAS PREPARED IN ACCORDANCE WITH THE
EXISTING CODE -OF PRACTICE FOR LAND,SURVEYS
ADOP-TED By THE N. Y.S. ASSOC...-,OF, PROFESSIONAL
-
CERTIFICATIONS SHALL RUN ONLY TO THE PE RSON
FOR WHOM THIS SURVEY WAS PREPARED AND ON,HIS
BEHALF TO THE TITLE CO. AND LENDING .INSTITUTION
LISTED HEREON.
SAID CERTIFICATI-ONS -ARE NOT TRANSFERABLE TO.
;ADDITz.IONAL I-NSTITUTIONS OR SUBSEQUENT OWNERS.
,FDONALIJ J. L i No 490 00
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101F419101fly "Filw4plhla CORP
Pllf bY.11104-Vee CONAIA(K
..UNAUTHORIZED- ALTERATION OR ADDITION TO ThIl S
liNDERGROUND STRUCTURES, IF ANY, NOT SHOWN.
-AJ-'L CERTIFICATIONS,ARE VALID FOR THIS MAP
AND COPIES THEREOF ONLY - IF SAID MAP.OR COPIES
BEAR THE IMPRESSED SEAL. OF THE 'SURVEYOR WHOSE
SY.GNATURE- APPEARS HEREON.
D
-qNALD J.. DONNELLY, L-.'S.
_�9
COMMERCE STREET
KTOWN HEIGHTS
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