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HomeMy WebLinkAbout0119DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 3.20 -1 -64 BOX 2 00119 rw 1�. r 11 , ILI IN 00119 W3 PUTNAM COUNTY HEALTH DEPAR7MENTP DIVISION OF ENVIRONMENTAL HEALTH SERVICES OWNER'S NAME tr . - 14 �b 11 Ir PHONE P6 -- $W' 2.. SITE LOCATION ,.S�-) (- iii a—. 'OAVZ 6.10 7Ma 37z yao MAILING ADDRESS 1?0 • 7 rx Z . DATE PCHD Complaint # Name &Relationship (i.e, owner, tenant, etc.) TYPE FACILITY ��?tbL�+1i?J�}�r PHONE aW , 606* 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. WIWI ?.".q .✓c� Proposal approved Inspector's Signature & Proposal Disapproved 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. Date/ 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. I, as owner, or reported ag Opt of owner agree to the above conditions. SIGNATURE �� =�� n.�� TITLE f/ DATE .. : indite (PCD): YeLlcw (kwn EI); Pink (AMticant) House A B 3 - 180 Contacts Gally #1 with stone 7 i Jct Box Gal�ly #2 �D9 1000gal Septic tank Oj <:f— Existing Drywell for Wash machine '• f Micheal Alpert ti South St. Patterson, n.y. 7 -8 -94 Bottge Septic Sodom Rd. Brewster, N.Y. y J¢ 412 /'5 ) 070 /go C4 a2 7j c 1 Bel . 17" Bottge Septic Sodom Rd. Brewster, N.Y. 1�� J �1 R "AQ" P- �o�a b- 0