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Home My WebLink About0350DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 13. -2 -52 BOX 5 or r oy'" -146A I Ll No - I Ill is L IN i y T f r A - 00159 d PUTNAM COUNTY HEALTH DEPARBCff DIVISION OF ENVIRONMENTAL HEALTH SERVICES PROPOSAL PIOR SE14AGE DISPOSAL SYSTEM REPAIFt 41; 3 OWNER'S NAM PHONE S hj1fd17_- ION i.I ADERESS PCHD Camlaint # aRlatioship. (i.e, on,tnt, etc.) MTE TYPE FACILITY DBTALLER :PROPOSED PHONE iREGISTRATION # i P=M3al (include sketch locatin.9-all adjacent wells): 4NO►E- Repair must be in same location and of same=type.as original sewage. disposal system. Different location may require submittal of proposal fran licensed professional engineer or 1-:'`registered architect. ter/ Zr 7 ff ,,e 31, 142 k- !T7roposal a Proposal Disapproved Inspector's Signature & Title ,.�'Prcposal 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 I s flow b. Site Street.Naper Town and Tax Map number. c. location of installed canponents.tied to two fixed points (e.g.,house corners). -septic tank,, three precast 61 dim. x 61 deep d. System description (e.g., 1250 gal. concrete drywells surrounded by one foot + gravel). 1 e. Installer's name and number. 3. System repair to be performed in accordance -with the above proposal and conditions. as owner, or reported agent of owner agree to the above conditions. SIGNATURE TITLE DATE White (MD); YeUcw (vn HE); Ark 0921aait) Dr-DD 67 77 419 IS 017 ©. 1,1v S'a / D OIC/ Se?tl "Z-"/ 7,911 -1 4>.o N ,. til J Ve LAI -4, q J--L V P C, �v 3 N i I