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HomeMy WebLinkAbout0225DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 4.18 -1 -46 BOX 3 oMi l; _„ ` F . , ,IN IL No No � T 111 I` Voi ol y �� _ i� No J41 A WNW I if I I• , o A . 00034 PUTNAM COUNTY HEALTH--DEPAR7Y►�TT /. DIVISION OF ENVIRONMENTAL HEALTH SERVICES 225 -0310 _ PROPOSAL FOR SEWAGE DISPOSAL SYSTEM REPAIR t -' OR °S NAM rd y PHONE �y- SITE I=TION 2 0 �d �,� rQ rh a� f r `d�° TO NAILING ADDRESS PERSON INTERVIEWED PCHD Complaint # Name & Relationship (i.e, owner,tenant, etc.). 2 TYPE FACILITY PROPOSED INSTALLER �� PHONE (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 architects f, .7 P -5 Proposal approved < Proposal Disapproved 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. Nation of installed capponents tied to two . fixed points Je.g. ,house corners) . ;d. System description (e.g., 1250 gal. concrete septic tank, three precast 61 diam. x 61 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 agent o owner agree to the above conditions. SIGNATURE TITLE DATE FPM' W-dbe MD); YeUjcw (7bwn BI); Pink - x.. � . I _ I - - . � 1. - I - �111 f­�� ,- � , , ��,z­'A/-- ­k 1 " - " �- ­ I AfteDolm - 4 V;I� _� , �,­Iw _ - , - , ., , - . 1� , - ,;" ­ , -, - I . I ;�-,­� ,,, ...., �- " _� . , - � . I . � ", , � . � - 11 _>,� ,I � I . , , ,; , .� �`,� - -, - � , - ,­_ �,,��_ � - � ,.klnmm =UNT_Y__',1M!Ar,T.W_M , , -, - - ka- ,,., , " -, .1 � I HEALTH - - ­­­ ' . 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'of P=Poml from licensed pofess cw --- a__- -- -- a� ,mac ..® ZT • o � � ►'� vq a �"' C� / r 4B a Pap de A 41 DRte [(. �'S.v: _a'i. '� :•:� '.: > ; � . ', � 'i . .: "'•r } ti. ai , Io AS amwo, or reported &Amt owner agree to the abom ooncUtions. Trffz mm ftto )g Yellow Mm Sl)$ Pke JUL -15 -2003 TUE 09:41 TEL:845- 278 -7921 NAME:PUTNAM COUNTY DEPARTMENT OF P. 1 JUL -15 -2003 TUE 09:42 TEL:845 -278 -7921 NAMETUTNAM COUNTY DEPARTMENT OF P. 2