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00795
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00795
Sheet I of _/
PUTNAM COUNTY DEPARTMENT OF HEALTH
__DIVISION OF ENVIRONMENTAL HEATLH SERVICES__
FIELD ACTIVITY REPORT
NAM E& PaLL06-k Tel: 'T�
ADT)RF4R: rf2.50 0/1 _ 21-2" P6 SOvL ti?.
Street I Town State Zip
PERSON IN CHARGE /
()R TNTFRVTFWFT). -17�W aJI 75 T)atP' / �L / / / oC,
Name and Title
TYPE OF FACILITY:
Signature and Title
REPORT RFC'FTyF,n RV:
I acknowledge receipt of this report: SIGNATURE:
02/96
Rev.
Title:
n .
Proposed'repair sketch
Install "D" box,
to control flow to
lower pit
}
ex. pits 75+
yrs old
I
..
Pollock 14 �m-fer
=4250 Old Route 22
Patterson NY
well
vd/1
'f4 ys J`r q
6;Y c
SiMve.J
14VV4
LIvo
C p6�jAc
Install "D" box,
to control flow to
lower pit
}
ex. pits 75+
yrs old
I
..
Pollock 14 �m-fer
=4250 Old Route 22
Patterson NY
well
oe-
'f4 ys J`r q
Guest house
Pond
to be removed.
r
well 200
,�k
oe-
f'2
ex. 2,000 gal
cesspool, V- 2
area `in gray'
to be removed.
Replace with
stone.
i i'3',.cF., _,..` ,ion- x`a' .. '.rta. a a.._ _'° .� _n- t
b
e_Q Ct %R- t n S��ZS
PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
1- 7NUMSEWTO
SITE LOCATION q 2-S- -)-2.
OWNER'S NAME o
MAILING ADDRESS PX 6
�u' .1 ; o
OFFICIAL USE ONLY
# ?
0(0
PHONE A!. --
PERSON INTERVIEWED N 4 �_elr � Wh PCHD Complaint #
ame Relationship I.e., owner, tenant etc.
DATE 10 I O 1, _ TYPE FACILITY 1R mss,,
PROPOSED INSTALLER
ADDRESS
REGISTRATION# 13
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.
I, as owner, or reported -agent of owner agree to the conditions stated on this form.
SIGNATURE TITLE
Proposal approved with thilomdag conditions:
1. Procurement of any Town permit, if applicable.
2. Submission of as built repair sketch in duplicate showing:
a. Owner's name
DATE �
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
e. Installers' name and number.
3. System repair to be performed in accordance with the above proposal and conditions.
Proposal approved.
C A . ep
s Signature & Title DATE
COPIES: White (PCHD); Yellow (Town BI); Pink (applicant)
PC -RP 991ML
FOR ADJOINING AREA SEE MAP NO .8
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