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01140
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PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
PROPOSAL FOR SEWAGE DISPOSAL SYSTEM REPAIR
OFFICIAL USE ONLY
SITE LOCATION <e- s6ro TM #�n�• •_6 - /_IXZ
OWNER'S NAME e PHONE &3 _YLq 7- 46 S
MAILING ADDRESS 2 dale ; � u6rwnmc CT ac RS 1
PERSON INTERVIEWED PCHD Complaint #
ame & Relationship i.e., owner, tenant, etc.
DATES 0 L TYPE FACILITY S'M S
PROPOSED INSTALLE 60,f neS ,►- .c_ PHONE S , 70% ?j
ADDRESS REGISTRATION# &; �r(o
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 rep_ o d agent of owner agree to the conditions stated on this form.
SIGNATURE TITLE Gi DATE 3
Proposal 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 comers).
d. System description (e.g., 1250 gal. Concrete septic tank, three precast 6' diam. X 6' deep
e. Installers' name and number. i
.
3. System repair to be performed in accordance with the above proposal and conditions.
Proposalapproved
Inspector's Signature & Title DATE
COPIES: White (PCHD); Yellow (Town BI); Pink (applicant)
PC -RP 99ML
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PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES V
(3rewsfie rr l�
SITE LOCATION `I —%�1CQ 4 6-e p R TM#
OWNER'S NAME
MAILING ADDRESS LA n-00 Nr, AI A& tJ]Al t -7—
EM REPAI
OFFICIAL USE ONLY
,R 0 a ,03
MW lb-110
06x5 i
PERSON INTE VIEWED PCHD Complaint #
Name & Relationship i.e., owner, tenant, etc.
DATE R TYPE FACILITY
PROPOSED TALLER �-� , RR Iai; S .0 _ PHONE N S- a%
ADDRESS f REGISTRATION# PC-
i r
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 p ed a ent of owner agree to the conditions stated on this .form.
..
SIGNATURE TITLE C n►U A7TA r_h i�_ DATE 3
Proposal 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 comers).
d. System description (e.g., 1250 gal. Concrete septic tank, three precast 6' diem. X 6' deep
e. Installers' name and number.
3. System repair to be performed in accordance with the above proposal and conditions.
Proposal approved i C
Inspector's Signature & Title
COPIES: White (PCHD); Yellow (Town BI); Pink (applicant)
PC -RP 99ML
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P.O. Box 266, Bedford Hills, NY 10507 (914) 666-2570 (845) 278-7073
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