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BOX 13
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It 61 IL
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OWNER'S NAME
SITE LOWION 3 R,0 To %° SO
MAILING ADDRESS IVY
PERSON INTERVIEWED PCHD complaint #
Name & Relationship (i.e, owner,tenant, etc.)
DATE TYPE FACILITY
PROPOSED INSTALLER PHONE
PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF aviRamERrAL HEALTH SERVICES
PROPOSAL FM S39M DISPOSAL SYSTEM REPAIIt
REGISTRATION #
Pr (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 o of proposal fran licensed professional engineer or
registered architect. —1 f ,� -7
d+tr'.VAW Na 4J
,f-7i9N C 13FTff?
Proposal appr Proposal Disapproved
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Inspector's Signature &
'roQOSal auaroved 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,
drywells surrounded by one foot + gravel).
e. Installer's name and number.
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DR/td-
(e.g. #house corners).
three precast 6' diem. x 6' deep
3. System repair to be performed in accordance with the above proposal and conditions.
I, as owner, or remorted agent of owner agree to the above conditions.
SIGNATURE .s0 6A TITLE DATE Y "C7%
[l�'T & ?bite (PAD); Yel1cw (fin HE); Pink U°plicmit)
PC -RP 97
�J
:aCl DIVISION OF ENVIRONMENTAL HEALTH SERVICES
225 -0310
PROPOSAL FOR SEWAGE DISPOSAL SYSTEM REPAIR I 4
�W �0
Oi�'S NAME BENJAMIN CAMPANARO JR. PHONE 878 -6500 OR
SIrETIACATION 23 ALDEN ROAD # 279 -4972
ANG ADDRESS PATTERSON NEW YORK 12563
Fm INTERVIEWED PCHD Camplaint_#
{ Name & Relationship (i.oe, owner,tenant, etc..)
M TYPE FACILITY D it _S .1.9
-: pROFSED INSTALLER PHONE 2.7� S� S
,Pro sal (include sketch locating all adjacent wells):
;.:.,16M, Repair must be in same location and of same type as original sewage disposal system.
Diffecent location may require submittal of proposal fr®n licensed professional engineer or..
`! regItered architect.
,Proposal
Ins
rrc
1.
2.
appTvej Proposal Disapproved
's Signature & Title baba
approved with the following conditions:
Procurement of any Town permit, if applicable.
Submission of as built repair sketch in duplicate showing:
a. Owner's name.
b. Site Street Name, Town and Tax Map number.
co Location of installed carponents tied to two fixed points (e.g.,house corners).
d. System description (e.g., 1250 gal. concrete septic tank, three precast 6' diam. x 6' deep
drywells surrounded by one foot + gravel).
e., Installer's name and number.
3. System repair to be perfonned in accordance with the above proposal and conditions.
as owner, o reported agent of owner agree to the above conditions..
8IGNATi7RE `' TIME ' DATE r
al�M: Riite MD); YeUcw (Tam SL);. Pink (Aal amt)
'r.
- _.._ ......_. 0,J fps
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