HomeMy WebLinkAbout4779DOCUMENT CONVERSION SERVICES PROVIDED BY
IMAGING & MICROFILM ACCESS, INC.
www.scanyourdocs.com
631- 589 -8100
91.26 -2 -8
BOX 36
I7-
T
r�
T
•
16
Ner
;w
�
,.
;I'
.6
,
tip!
'
T
�:
I .a
I
�
,.
;I'
.6
,
PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
PROPOSAL FOR WAGE DISPOSAL SYSTEM REPAIR
OFFICIAL USE ONLY
Ica
SITE LOCATION TM# q /,, , a
OWNER'S NAME 4:r Kh er PHONE
MAILING ADDRESS l
PERSON INTERVIEWED G�i' PCHD Complaint #
Name a ations ip i.., owner, tenant, etc.
DATE d �/ { TYPE FACILITY
PROPOSED IN6AZER PHONE
ADDRESS 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 proposal from licensed professional engineer or registered architect.
1,_asow er rr_te orted aaPpt:o wrier-ag3ree_ cio n"tated on_this.f .,.: '::...
-
SIGNA TITLE Pte' 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
1�
Inspector's Signature & Title
COPIES: White (PCHD); Yellow (Town BI); Pink (applicant)
PC -RP 99ML
ATE
,
oll
5
iA-0 .Ol