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01239
PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
SITE LOCATION La
OWNER'S NAME
MAILING ADDRESS
OW
250 �C/
PHONE q14-2.15-1295_
14- 2"18-129
PERSON INTERVIEWED Ani,�,onu RJa6Q(1,tz - Ownc'r PCHD Complaint #
Tam a atie s ip i.e., owner, tenant, etc.
DATE
TYPE FACILITY
PROPOSED INSTALLER -Tamp v%il,Akia eeN►pk4,e — Ou,ne.r PHONE
.1VM
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.
taco P4. 'b, mlae. , Q" is se-4, uA LA ' rfrart -Fire- &u v n.tt .
has owne or rep rted ale _o er agree to the conditions stated on this form._ 11 aa��rr��
SIGNA �. TTTLE duuner DATE w.1w ' b . 2 «lV
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.
3. System repair to be performed in accordance with the above proposal and conditions.
Proposal approved_
Inspector's Signature & Title
COPIES: White (PCHD); Yellow (Town BI); Pink (applicant)
PC -RP 99ML
DATE
IA
6, , a PHONE N4. 17182634165 Jul. 08 1997 04:51Ph1 P2
FRGM MED. HALL. — PHARM. —f. K . N. Y. '
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PREPAREQ
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OF PLITNAM
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SITE
PERSON INTERVIE Pty Complaint
Dame & Relationship ( i. o e, owner, tenant, etc.)
DATE TYPE FACILITY
PH=
Pr sal (include sketch locating all adjacent wells):
NOM: 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.
C [.C/2_Cwn:nCc _
Proposal r e
Inspector's Signature & T:
tl.e
Proposal Disapproved
NFIN
'roposal approved with the following conditions:
1. Procurement of any Town permit, if applicable.
20 Submission of as built repair sketch in duplicate showings
ao Owner's name.
bo Site Street Roane, Town and Tax leap number.
c, location of installed components tied to two fixed points (eogo,house corners),
do System description (e.g., 1250 gal. concrete septic tank, three precast 61 diatmo x 61 deep
drywells surrounded by one foot + gravel)
eo Installer's name and number.
3. System repair to be perfonred in accordance with the above proposal and conditions.
I, as owner, or reported agent of owner agree to the above conditions.
t _
s 6�Lite (PCEID); YellcN (Tam ffi)a Pink (Anliamt)
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750gal
WEDCO SEPTIC
TANK
GALLEY
AL GOTTSMAN
U LAKE SHORE DR
PATTERSON? N Y
R-228-91
GALLEY* 3
6,1
A B
TANK 1
181
221
TANK 2
221
19,
GALLEY1
481
15'.
GALLEY 2
471
12'
3
601
22'
HOUSE
750gal
WEDCO SEPTIC
TANK
GALLEY
AL GOTTSMAN
U LAKE SHORE DR
PATTERSON? N Y
R-228-91
GALLEY* 3
6,1
A B
TANK 1
181
221
TANK 2
221
19,
GALLEY1
481
15'.
GALLEY 2
471
12'
3
601
22'
GALLEY
Installed By: BOTTGE SEPTIC, INC.
SODOM RD.
BREWSTER, N Y 10509
AUGUST 28, 1991
914 279 -6069