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HomeMy WebLinkAbout4749DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 91.26-1-35 BOX 36 04749 r o; V PUTNAM COUNTY HEALTH DEPARTMENT DIVISION OF ENVIRONMENTAL HEALTH SERVICES cis 7 -_ _Z 49.- ..a s `� . .a+ ... .. -7 �.� . ;, P. ':$:.. w-.t- 'v;iu.d4L. sYoc:. p ?,...N ♦i"gt� -T�O'n + K ` . .. w PROPOSAL FOR SEWAGE DISPOSAL SYSTEM REPAIR OWNER'S NAME Y `0 OA,7- De 0q,6,*k J f�.k'if 0 PHONE SITE LOCATION n4j! 4. N tc4. PL To 9 /'R 6 " 0_1 MAILING ADDRESS oicgyct /0 5--3 % PERSON INTERVIEWED PCHD Canplaint # Name & Relationship (i.e,owner,tenant, etc.) DATE / J� 1 TYPE FACILITY PROPOSED INSTALLER Me. :,v Ali' fin. % PHONE 'S"9CS"r REGISTRATION # J- 7r, 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. C / IW I- I- 0 r -, -T/d A' 's & Title Proposal Disapproved Date roposal 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 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. 7 I, as owner, r reported agent of owner agree to the above � conditions. SIGNATURE -- DATE 0-/J (o .. & Wdbe MV; Yellrcw abwn BI); Plink (k#iamt) ,�;n W V 'VY PUTNAM COUNTY HEALTH DEPARTMENT DIVISION OF ENVIRONMENTAL HEALTH SERVICES PROPOSAL. FOR SLWAGL DISPOSAL SYST) RE OFFICIAL USE ONLY SITE LOCATION 3 � L P� � � TM# � �� 2 3S' OWNER'S NAME P PHONE _'Z8 -- 6 Y 39 MAILING ADDRESS PERSON INTERVIEWED PCHD Complaint # ame & Relationship i.e., owner, tenant, etc. DATE �k 191t. a(. TYPE FACILITY 90-f ,PROPOSED INSTALLER r tfJ�'� PHONE ADDRESS D40 PA-9 Pv'r�rrvW pt(,a q REGISTRATION# Proposal (include sketch locating all adjacent wells): (Q4, 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. I, as owner, .- °ported agent -of owner agree to the :conditions stated on: his fortr. SIGNATURE TITLE ('�O� DATE P I Z' 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 DATE COPIES: White (PCHD); Yellow (Town BI); Pink (applicant) PC -RP ' 9.9M L.