HomeMy WebLinkAbout0236DOCUMENT CONVERSION SERVICES PROVIDED BY
IMAGING & MICROFILM ACCESS, INC.
www.scanyourdocs.com
631- 589 -8100
4.19 -1 -17
BOX 3
4171111
wl
Ll
*r
T
r
I
jr
00045
OWNER'S NAME
SITE LOWION
FILING ADDRESS
PERSON INTERVIEWED
61.W.11P
PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
PROPOSAL FOR SENAGE DISPOSAL SYSTEM REPAIR
PHONE
PC HD Canplaint #
Name & Relationship (i.e, owner,tenant, etc.)
TYPE FACILITY
PHONE Ald
REGISTRATION # 3q 7/
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.
WNW liiiiii
Da
'roposal approved with the following conditions:
1. Procurement of any Town pernnit, 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 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
gen of owner agree to the above
conditions.
SIGNATURE
TITLE
DATE
QP1ES: White (FUG); YeUcw (man HE); Pink (Appliamt)
Pr-pp o,7
OWNER'S NAME
SITE LOCATION
MAILING ADDRESS
PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
PROPOSAL FOR SEWAGE DISPOSAL SYSTEM REPAIR
PHONE
TO
ins -y7
cR,,7S d -7, � 5 - /
PERSON INTERVIEWED ' PCHD Complaint #
I Name & Relationship (i.e, owner tenant, etc.)
DATE I / / ) TYPE FACILITY
PROPOSED INSTALLER) PHONE
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.
v---� a e _ a 1�1�
Inspector's Signature &
rorosal aooroved 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
d. System description (e.g., 1250 gal. concrete septic tank,
drywells surrounded by one foot + gravel).
e. Installer's name and number.
�Q
D8
(e.g. house corners).
three precast 6' diam. x 6' deep
3. System repair to be performed in accordance with the above proposal and conditions.
I, as owner, or regprted agent of owner agree to the above conditions.
SIGN ATURE TITLE
. kV 7), X X�
13�" 11: White (PQ:D); Yells w 030 BI); Pink (Applicant)
DATE
UTNAKICOUNTY DEPARTMENT
CO 'Bloc
qwner Lot Job
Separate Sewerage System Address
A-66 16
Consisting of Septic Tank TT lineal Feet X width _,trench'
Water Supply: Public-Subply From i--02 i
Piilvate Supply Drilled By,
Address
Building Type No. 'of Bedrooms
.14as osion Control Been Completed?
Ole
I certify that the system(S)r'aS listed serving the-ab6ve -premises were constructed essentiajly,',as*shown o . n . ;th plani��f,the corn
pleted work (copies (if which a re"
Dat'e /0 Certified by
0.
Of
Any person occupying premises served,by -the above system(s) shill ip�mptly-take such' ac ion as may- be necessary to secure the correction to any yn�anitary. -
conditions resulting from 'Such umge,_,ApprovaI of the separate, seweraget system shall. become* null a.�h,d void'as.sdon'as a pub ic sabi ary sewer becdmet
a�ailable and the approval.of the prhiat.e Water suIliply.shall'become null and voic!4-�vhen a isublic'wat&r supply becomers available. . Such aobrdva.15 are
subject to modification, or, chan§e.rwheri, in the judgment of Ahe Co '0 ealth 0 Yd)fication change is neceisar
`
bpi
V% 11h,
L o c.
7T------ -
B'
Lo •;
0 n
con
yY r J J _ f _ r n - ~ ' ` - �. ... � � _ • - - _ r V •�• - - - - J V - - - - � J .-. r v , . _ ._ ... r _` .t -
Z Z
T'L- 7 zt
ac
Da 0
k 44 . to O-ep- a,, Rol-&
S
0 F
-�- -#,.!, -1 I
.1 lins ,�-J,I- , , - �, � -
?-, mll.,�,. I ,
, .11 �, L - ,,�-� - - - 1;� , A40--, - - , . - .
, , , � 4, , :#-, , -,- I � ,��
-,q - ., � , � � i , , � , ..
4�� - "'! ,.. , ,,�Iv�-Ir6�b-f �,,, L rl :4� " :, � ,a,01*42 ,�
, �N - � - ,-%--, N��. � 5- - , , � , - - -
-� -�4 -� , , -Z W
I 11
+ ll�
, llt-,�
,�� , - - ,,-.1 - W., --- ; -f-, A"'r, li,f- . � - - -` 1111% eSl- I . " I ,�- -1 ,�,, - I., -, �
-