HomeMy WebLinkAbout4816DOCUMENT CONVERSION SERVICES PROVIDED BY
IMAGING & MICROFILM ACCESS, INC.
www.scanyourdocs.com
631- 589 -8100
91.33 -1 -37
BOX 36
i
PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
PROPOSAL FOR SEWAGE DISPOSAL SYSTEM REPAIR
i
OFFICIAL USE ONLY
�-- q 1 -f
I
SITE LOCATION -% (JcK
OWNER'S NAME d+r s
MAILING ADDRESS �7 4
orelo
TM# U d 3 / —J %
PHONE (f V) 9f 0q z
II /tom: 10537
PERSON INTERVIEWED CA,-fj Morm, PCHD Complaint #
Name & Kelationship (i.e., owner, tenant, etc.
DATE �] 12 �� TYPE FACILITY Pdv-* �Dwe ll��►�
i
PROPOSED INSTALLER 06th- PHONE 9/`/ ef?9 5256
ADDRESS Score 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.
i; -as owner; or-reported agent of owner agree to the conditions stated on this form. j
SIGNATURE TITLE QWhC0- DATE �IIz L�
i
Proposal approved with the following conditions:
1 Procurement of any Town permit, if applicable.
Submission of as built repair sketch in duplicate showing:
a. Owner's name
3.
b. Site Street Name, Town and Tax Map number.
C. Location of installed components 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
e. Installers' name and number.
System repair to be erormed in accordance with the above proposal and conditions.
' approved� —��,
,e_ / /
s Signature & Title
COPIES: White (PCHD); Yellow (Town BI); Pink (applicant)
PC -RP 99ML
i
DATE
Ct
i
W� AIfr,Aaf -s
l,00o
r
d
i�
�9
I
Lk.
O&ASL
i
PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICE, S
1
PROPOSAL FOR SEWAGE DISPOSAL SYSTEM REPAIR
OFFICIAL USE ONLY
SITE LOCATION 7 0c, r PL TM# W-1 1 J3 — 63 7
OWNER'S NAME C hri&4-4 tr- Marw, PHONE OP-IS) 52P-1092
MAILING ADDRESS -7 0,41 PL L/ f- Pm sti-01 AlY, / 0537
PERSON INTERVIEWED Ck PCHD Complaint #
e ations ip i.e., owner, tenant, etc.).
DATE � �%`'fl � TYPE FACILITY PIA ^4 0-t/ ti!.
PROPOSED INSTALLER (DWA`<' PHONE qi IL ' J-7 `
ADDRESS �r��h REGISTRATION#
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.
1vAJ
I; 816";,M ei; or iep tted /ent oaf ownEfagreeio the eonditioris'stated on ti�s'fornT.
SIGNATURE °�� /L� �" TITLE 0(,/M 'tr
Proposal approved with the following conditions:
1. Procurement of any Town permit, if applicable.
2.. Submission of as built repair sketch in duplicate showing:
DATE
i
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 pe ormed in accordance with the above proposal and conditions.
Proposal approved
7/7 01
pector's Signature & Title DATE
i
COPIES: White (PCHD); Yellow (Town BI); Pink (applicant)
PC -RP 99ML
�7 4gIT PL a
r
�r
r
r
r
k
r
Nx-
s� t
I
r
i
�f
S
'= �6 611
i
�t
I
i{
1
Sr2L =C-7'
�x
r
r
r
t
.o
Al
#30 `o
k
k
f
t
f
qt r
3
1
E _
4:
1
!4"o'j 61'wj 110 6601
.
i
aq
j
,LS
r .t
b'1
1
a
r
�+►alG. �'.J,A� J