HomeMy WebLinkAbout48691W
'(SITE LOCATION
OWNER'S NAME _
MAILING ADDRESS
kJ U(ir- i�VyPS
PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
PROPOSAL FOR SEWAGE DISPOSAL SYSTEM REPAIR
3 &Rcoe/z
L, L 9—
OFFICIAL USE ONLY
%.41
�-
TM# S 9, 1-3 — l -- 13
PHONE 5-2- V-`79 I
PERSON INTERVIEWED PCHD Complaint #
ame & Relationship (i.e., owner, tenant, etc.
01 1 DATE S I kv TYPE FACILITY
(31 (:LAC I.2 r"
PROPOSED INSTALLER � � ,Sc �,,j,g �� 2,K KD , PHONE 2-
ADDRES S E,j I-N/Am kAJ C, L.,y. 3bf , , l O, L72 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.
IN
._....:.,.as Aorf6ed ageht�mf c:vrser ab.,�e��� the =con:�r�_orrs�sta�., �on- � -. -. _..._.... �.._. _ ':..._..::..�.... :; ..
d` flue ,,,rm. -
SIGNATURE TITLE A & cw- DATE
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
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 descript' - n (e.g., 1250 gal. Concrete septic tank, three precast 6' diam.
e. Installers' a and number.
3. ' System repair to be erformed in accordance with the above proposal and conditions.
Proposal approved
pector's Signature & Title DATE
COPIES: White (PCHD); Yellow (Town BI); Pink (applicant)
PC -RP 99ML
X 6' deep
q3 i36ozcq, rL --
/?
p fie L L
45
��c�i �+�6 Sr �� T,+ IV
0 eta e
we CC
6 e
a e L 60
�`v T vim-
;r
f F SM
a
Or
3
�j 1.