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01368
PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIROMMAL HEALTH SERVICES
225 -0310
-PROPOSAL FOR SEWAGE DISPOSAL SYSTEM REPAIR' -�
OWNER'S NAME ANTHONY BARVINSKI PHONE 279 -7239
SITE LOCATION 7 ALDEN ROAD T
MAILING ADDRESS PATTERSON. NEW YORK 12 563
pEFSON INTERVIEWED PCHD Complaint #
Name & Relationship (i.e, owner,tenant, etc.)
DATE TYPE FACILITY
PROPOSED INSTALLER '
PHA
Pro (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.
WE
v
Proposal approved Proposal Disapproved r
's Siqnature &
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Date
F
roposal 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 corners).
d. System description (e.g., 1250 gal. concrete septic tank, three precast 6' diam. x 6' deep
drywalls 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, o agent of owneA agree to the above conditions.
SIGNATURE TITLE �` � DATE
V.
Lam: Rdte MD); YeUc.w (mn BI); Pink (Anlicsnt)
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