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BOX 12
01250
a
e
YES I
SITE LOCATION
OWNER'S NAME
PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES td s -d23-06
Internal Use Only
Repair Permit issued in last 5 years ❑ Not in Watershed
E) Repair within Boyd's Comers, W. Branch or Croton Falls Res. ❑ Delegated
Repair within 200 ft. of a watercourse or DEC - mapped wetland ❑ Joint Review
7 1.14 & - lo, TM # .2 �• 6 y ' �"' y3
PHONE # .2% 7,y S3 13 .
MAILING ADDRESS
APPLICANT
Name & Relationship (i.e., owner, tenant, contractor)
DATE r
� FACILITY TYPE � PCHD COMPLAINT #
PROPOSED INSTALLER its PHONE #
ADDRESS REGISTRATION /LICENSE #
Proposal (include a 'separate sketch locating the house; property lines, all adjacent wells within 200
feet of repair and the location of existing and proposed trenches)
NOTE: Repair must be in same location and of same type as original sewage disposal system.
Different location and proposed pump systems will require submittal of proposal from licensed professional
engine r or registered architect.
I, as owner, or reported agent of owner agree to the conditions stated on this form
SIGNATURE TITLE C
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
d. System description (e.g., 1250 gal. Concrete septic tank, etc.)
e. Installers' name and phone number
3. System repair to be'performed in accordance with the
above proposal a d con 'ti s.
Pr posal Approve Proposal Denied
I spector's Si itle Date
COPIES: White (PC—HD); Yellow (Tour I) Pink (Installer), Orange (Applicant)
PC -RP 99ML
Rev. 8/05
DATE l/ 6
Permit # GJS b 6
Robert J. Bondi :^ Cris Dellaripa.
County Executive Septic Repair Inspector
f i�►':�h�te ralermo
V — Watershed Information Coordinator Office Manager
•
PUTNAM COUNTY SEPTIC REPAIR PROGRAM
100 Rte. 312
Bldg..#4 ;
Brewster, NY-10509
:Date: /a/.701D 6
PCDOH
Attn: Michael Budzinski
1 Geneva Rd. "
Brewster, NY 10509
Dear Mr. Budzinski;
We wish to report that.the following job:
Name
Address 41? I ) a Y_� P n
Tax ID# 02 6 y. y3
has been completed as per the approved drawings.
As -Built Attached:. Yes No
CC: Dan Shedlo, P.E.
Telephone: (845) 278 -8313
Fax:'(845) 278 -2318
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Permit #
I!
Robert J. Bondi ter; Cris Dellaripa
County Executive �' Septic Repair Inspector
Edward _E A. _ Barnett _ ._.._ _..
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hele
WaWsfie3Ififormation Coocairiator` 6ffioe Rianager:
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PUTNAM COUNTY SEPTIC REPAIR PROGRAM
100 Rte. $12
Bldg. #4
Brewster, NY 10509
Date:
i
I
PCDOH
Attn:. Michael Budzinski
1. Geneva Rd. ! i
'Brewster, NY 10509, '
Dear Mr. Budzinski;
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Telephone: (845),278 -8313
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Fax: (845) 278 -2318
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30- 10 -`C,1 1__ FRO11 -PI, Septic & Repair $45 -27$ -2313 T -207 P002/002 F -125
Robert J. Bondi Cris 19ellsrlpa
County Executive Septic Rrpair inapector
iytfax l'alermo
- ~ Watw:shed Infornwtion Coordinator office Manager
PUTNAM CCTA41 Y SEPTIC REPAIR PROGRAM
100 Rte. 312
RUg. #4
Rtcwstet, NY 10509
Mrs. Sooae L.un
7 Interlaken Rd.
Patterson, NY 1.2563
Dear Mn. Lim;
October 30, 2006
Thank you for participating in The Putnam County Septic Repair Program.
As per the contractual agreement that you signed, you are now entered into the Maintenance portion of the
agreement. Your schedule for maintenance requires that you get your septic tank pumped every 2
!ears. Your fast scheduled pump -out should be before 10/24/2008. When you do get it pumped, kindly
forward to this office it copy of the receipt you get from the,Septic Contractor that you hire.
It has been our pleasure to Serve you. Should you have any questions or concerns, please do not hesitate
to contact this office.
ours truly - -
flch'ele ]Palermo
Office Manager
CC: Michael 13udzinski V
Putnam County Department of Health
Telephone: (W) 27941313
Fax: (845) 27&23na
OCT-30-2006 yJ -2006 NI-11 1 !.. TEL: ,x,15 -278 - i yr' -1 liAME: PUTNAM COUNTY DEPARTMENT OF P. 2