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01253
PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
PROPOSAL FOR SEWAGE DISPOSAL SYSTEM REPAIR
.YES .. NO . Internal Use Only
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❑ Repair Permit issued in last 5 years ❑ t in Watershed
El � Repair within Boyd's Comers, W. Branch or Croton Falls Res. LJ Delegated
a ❑ Repair within 200 ft. of a watercourse or DEC- mapped wetland ❑ Joint Review
SITE LOCATION . % 4fMiDn TM #
OWNER'S NAME 25l men PHONE #
MAILING ADDRESS,...
APPLICANT p w U+^a -r",
Name & Relationship (i.e., owner, tenant, contractor)
DATE /4' /V14)5 FACILITY TYPE PCHD COMPLAINT #
PROPOSED INSTALLER ®_ PHONE #
ADDRESS g /u-j12/2. 34 /•�1f REGISTRATION /LICENSE # {P
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 andproposed pump systems will require submittal of proposal from licensed professional
engineer or registered architec�.
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I, as owner, or reported agent of owner agree to the conditions stated on this form
SIGNATURE TITLE ,►CGS DATE l'U j) e
Proposal a ed with the followinq conditions:
1. Procu ment of any�Town Permit, if applicable.
2. Submission of as built repair sketch in duplicate showing:
a. Owner's name. C :
b. Site Street Name, Town and Tax Map number
c. Location of installed components tied to two fixed points ? i :?
d. System description (e.g., 1250 gal. Concrete septic tank, etc.)
e. Installers' name and phone numberr,'r
3. System repair to be performed in accordance with the crz
above proposal and''conditions.=
Proposal Approved ✓ Proposal Dqa dz 14.
Inspector's Signafdre & T10,
Ci
COPIES: White (PCHD); Yellow (Town BI)�ink (Applicant)
PC -RP 99ML
Rev. 8/05
SHERLIITA.ANIf ER,1dIID, MS, FAAF
Commissioner of Health
LORE'I I'A MOLINARI, RN, MSN
Associate Commissioner of Health .
October 13, 2005
O'Hanlon Excavating
Mr. Andres Jusino
8 Hawk Ridge
Brewster, NY 10509
Dear Mr. Jusino:
DEPARTMENT. OF HEALTH
1 Geneva Road, Brewster, New York 10509
Re:
".— ROBERT J. BONIDI
County Executive
Sewage Disposal System Repair Permit
I am writing in reference to the enclosed permit. Regretfully it cannot be processed
without a signature. Please sign and return.
If you have any further questions, please contact me at (845) 278 -6130, ext. 2261.
GDR:cw
. _ .. Cincetely, - - -- .. .. _ ... - :._
4 r'_� -0. 12 - �/
Gene D. Reed
Sr. Environmental Health Engineering Aide
Environmental Health (845) 278 -6130 Fax (845) 278 -7921
Nursing Services (845) 278 -6558 Fax (845) 278 -6026 WIC (845) 278••6678
Nursing Home Care Fax (845) 278 -6085
Early Intervention /Preschool (845) 278 -6014 Fax (845) 278 -6648
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PUTNM COUNTY M&%LT,H DWARMW
DIVISION OF EWIRONMMML HEALTH SERVICES
225-0310 ' �,i_�/
- . - �� �- O�`-� . - :. - - '-PROPOSAL FUR = MM - DISPOSAL . SYSTEM IWAIR
00M, S MW
0 u'&LL PHONE 278- 79,5-3_
SITE LOCATION L A�.Q� 6HAm �z go
MAILING ADDRESS
PERSON INTERVIEWED
PM Complaint #
Nkm.& Relationship (i.e, ownerlteriant,, etc.)
DATE 9 TYPE FACILITY
PROPOSED INSTALLER r3 iKl bC
Him ( )779
Proposal (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 fran licensed professional engineer or
registered architect. S-0 0 54 P6 m 0
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Proposal approved
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Inspector's
with the
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Proposal Disapproved
conditions:
11ate
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2 Submission of as built repair sketch in duplicate showing:
a. -Owner's name.
b. Site Street Nam, Town and Tax Map number.
C. Location of installed components tied to two fixed points (e.g.'rhouse corners).
d. System description (e.g., 1250. gal. concrete septic tank,,,three precast 61 diem. x 61 deep
drywalls surrounded by one foot + gravel).
e. Installer's name I and number.
3. System repair to be perfonred in' - accordance with the above proposal and conditions.
as owner, or reported agent of owner agree to the above conditions.
SIGNATURE TITLE
Vibe (MD); YeUm (T= 19); Pink (AgUa tit)
DATE
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