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01305
PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH-SERVICES-
PROPOSAL FOR SEWAGE DISPOSAL SYSTEM REPAIR
W Y�
OWNER'S NAME Emil Vi gi l i o PHONE 2 7 8 - 6 3 5 8
SITE LOCATION 50 Gates Dr. TO 43 -2 -15
MAILING ADDRESS Patterson,N.Y.12563
PERSON INTERVIEWED PCHD Complaint #
Name &.Relationship (i.e, owner,tenant, etc.)
DATE TYPE FACILITY 2 bed . r e s .
PROPOSED INSTALLER Va l l ey Excava t ing PHONE 245-2276
Pro (include sketch locating all adjacent wells):
NOTE: Repair must be in same location and of same type as original swage disposal system.
Different location may require submittal of proposal fran licensed professional engineer or
registered architect.
Install 12 high cap.Infiltrator sallies w /1; stone
in same area as existing.
Install one 1000 gallon Polyethylene tank in same place as existing
Proposal approve
Inspector's Signatur
tle
Proposal Disapproved
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 canponents tied to two fixed points (e.g.,house corners).
d. System description (e.g., 1250 gal. concrete septic tank, three precast 6' diem. x 6' deep
drywells surrounded by one foot + gravel).
e. Installer's name and number.
3. System repair to be performed in accordance with the above proposal and conditions.
I, as owner,'or reported agent of owner agree to the above conditions.
SIGNATURE ..... bL4 c*A TITLE PA,,j JtC DATE ,��►vksc,_ /6 : s s �>
CP'IRS: White (POD); Yellow Mkin HE); Pink (Anaiamt)