HomeMy WebLinkAbout4785DOCUMENT CONVERSION SERVICES PROVIDED BY
IMAGING & MICROFILM ACCESS, INC.
www.scanyourdocs.com
631- 589 -8100
91.27 -1 -17
BOX 36
I
i
NJ
NN
--i
r r
16
i-
S-im
- ��:1.1
J
T
IN
r
t
r
.k
.
04785
0
PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
.. r..w •'++�'�M: .q -..a "f ':T 0w _•"r ^- ..��: .... ....._ i r...mf -+-r MIS �. '+ •f -_..it T'ri.
PROPOSAL FOR SEWAGE DISPOSAL SYSTEM REPAIR
SITE LOCATION
OWNER'S NAME
MAILING ADDRESS
TM#
OFFICIAL USE ONLY
-�
(. �27 I l"
PHONE
,27
D
PERSON INTERVIEWED PCHD Complaint #
Name & Relationship i.e., owner, tenant, etc.
DATE f TYPE FACILITY
PROPOSED INSTALLER �K& trC� j °4- �6 k ooh., —PHONE
ADDRESS C� rt /aJ tity REGISTRATION# P�
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
as owner, or reported agent of owner agree to the conditions stated on this form.
f A
/
SIGNATURE TITLE C�WI�✓I` 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 d number.
3. System repair to be ormed in accordance with the above proposal and conditions.
Proposal approved
COPIES: White (PCHD); Yellow (Town BI); Pink (applicant)
PC -RP 99ML
DATE
J %�� &p
_►,� I trte-tvK's.
w,j, If)
V/ U-7
��o�.�d�
House
15 Enloe St
Lake Peekskill
A I B
A IB
1 78-9 81
91 103
3 97 108 Existing tank
4 102-7 113
Existing leach pit
Existing leach pit
2
4 rows of 8 chambers each
4
0
r System greater than 100 feet from all adjacent wells -
I
Sand and gravel soils
f (- (1- 0
9/4 q 8 v ?5-5-4
V�