HomeMy WebLinkAbout0622DOCUMENT CONVERSION SERVICES PROVIDED BY
IMAGING & MICROFILM ACCESS, INC.
www.scanyourdocs.com
631- 589 -8100
23. -2 -35
BOX 7
., r
ILL I
'.■ ' ,
00622
J'¢
OWNER'S NAME
SITE LOCATION
MAILING ADDRESS
PUTNAM 00UNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
PROPOSAL FOR SEKVM DISPOSAL SYSTEM REPAIR
R- 1 v -C,:3we
2 3 , a —3 s-
PERSON INTERVIEWED PCHD Canplaint #
Name & Relationship (i.e, owner,tenant, etc.)
DATE j z a ao ° q� TYPE FACILITY
PROPOSED INSTALLER 1, cY 0 Ve�h r. F 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.
-fro
Proposal approved X Proposal Disapproved
Inspector's Signature &
Dfite-
Iroposal 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.
c. Location of installed components 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 agent of owner agree to the above conditions.
SIGNATURE a Awn -�lL, ,ryJ i TITLE DATE 2,-Z
IP1FS: V&te (PQHD); YeUaw (vin HI); Pink (Applimnt)
V - � 2- jr 4 1 . . '-V L/-- X. -
A -7
m
.4
ti