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BOX 15
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01589
PUTNAM COUN'T'Y HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
PROPOSAL FOR SENAM DISPOSAL SYSTEM REPAIR �Va
OWNER'S NAME jIC PHONE
SITE IACATION i -3i' TO
MAILING ADDRESS
PERSON INTERVIEWED PCHD Complaint #
Name & Relationship (i.e, owner,tenant, etc.)
DATE TYPE FACILITY
PROPOSED INSTALLER PHONE 0'749- 6og l
REGISTRATION #
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.
i
Proposal approved }_- Proposal Disapproved
Ins r s ignature & Title Da
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 (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 TITLE DATE S 26 -a—,_
I PAS: Vhite (POD); Yellow (fin HI); Pink (Appli®nt)
Rk. -9;. ,mot 5
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PUTNAM COUNTY DEPARTMENT OF HEALTH No. 130-95-19
----SOUT14EAST
TAKEN BY PM
CONFIDENTIAL
COMPLAINT ORSERVICE REQUEST RECORC(��
:DATE,:. -2/27/95 'TO .
TELEPHONE CALL X ' IN PERSON' LETTER
REQUEST FROM Grace Romasanta TELEPHONE 278-4947
ADDRESS 1C Farm to Market Road, Brewster
ENVIRONMENTAL HEALTH: Home Sewage Rodents Refuse Public Water Food Service
Migrant Camp
COMPLAINT OR REQUEST Field & Forest (Now Forest View), raw sewage, not completely
cleaned up. Sewage and paper in pit mm at rear of property.
77
ESTIMATED TOTAL MAN HOURS SPENT
1 _f.—a— l
1 � �' _ . • ..• /. 1. • .+._.. ..t.t. a... •.<v �<_t.. ._.•.... .. .. _.. a.. ... .. .. .. -..'
PUTNAM COUNTY DEPARTMENT OF HEALTH
a,'n COMPLAINT OR. SERVICE
-•
PATTERSON = = DATE - 4/10/95 -° T REFERRED TO
TAKEN BY MK TELEPHONE CALL X IN PERSON LETTER
Ile
CONFIDENTIAL
REQUEST FROM Hunter Pollock TELEPHONE 878 -3530
ADDRESS_ Old Rte. 22, Patterson
152 -95 -19
ENVIRONMENTAL HEALTH: Home Sewage Rodents Refuse Public Water Food Service
Migrant Camp Other
COMPLAINT OR REQUEST Possible septic leak. Apartment complex on Farm to Market Road,
between 311 & 164, 1st left off Farm;.-.to Mkt. across from Brewster Central Schools.
Far end of parking lot, dirt road, take short distance, pool of water - x5m. e
strong odor.
ACTION TAKEN BY �-• bATE
FINDINGS
FOLLOW UP INSPECTION (s)
DATE r FINDINGS
DATE FINDINGS
PROBLEM ABATED
DATE
77
PERSON NOTIFIED
ESTIMATED TOTAL MAN HOURS SPENT
r
v 'f` + �:.,.nr iy ?� -�- ._� / / 1 � ''� +r" fl � `�'F r � °'�'- r.. Fr ,�' + a f .: 4ra t� t�� nY•� j.
_" =4,. .... .1.... � _, ._s,..,y. _ -,. ,,. ,. _.... �...0.::1....- :'z'���r.. .. r.l_...... , -..]�. .._ � -_.�.t _... x_,...,,s ''.Y_.. .i�.._r_.x.?. tl µ} ...r..: *,•r 5 �.
1. responsible, you are request edf "to, notifyi �mme
T rA1 �i��i,prr fir^' Y' ai'r `rrl,5 ,. rF '{nfi:7'�,
o riate steps must
eased be advised` that ° apps
Pl p,�
overflow cease by arrangingfortheseptc =ta
etl
_.properrepaars..ars madga
to, thesystem
Approvalof proposed repairs must be obtained
rebuilding ,of existing disposal - `systems. An'
r r
Failure to- maintain the septic tank pumped ar
May 10 " 1995 wi 11 make you ,liable for additic
on a charge of committing a:. violation punish
imprisonment, as prescribed�by law, in addit
:- reinspection wiTi =be made n:
It is sincerely hoped th
that e above menti6hi
will cooperate by securing .the ..correction 'of'
For Th
Very ti
Bruce. �
- - Acting;
BF /MK/i P
Enc Permit. Application En'
cc t4� BIl (T)f Patterson
i'Nj'r." �'+#
t� ti r x �? c 4c tly eef�t fyy ° *R ti3 Y ter,. *M
iti�i°fi,_`.,•9"�. -�rEe - 1. .i,�4, X33'" i... 5- }L�'c,L.'�.,",'r`:�'•..e,'.�'+'
y.,
��of tnetgroua
"'Rag th%
`of the not
e
nu, o,
1 , �i'
Y �
ii t on 5 I f< y garwti�� },!ti
above indicated � r;
i n order that; y he sewage
i7; n , , -7G , `''Y' ?kY".;x4 j� rrx _ -
�d maintained pumped�urtiAiu the
a « f c rx
prior
to,. anyhalter�-ti*onF�or
ed urf �Cda {y "c.
y ,.+..
t�-r rc,},x T _
dtb1Sl,aa -IN . cludbng .,pr secution
... 1 . ! .. .. ....r..... c rn..a�.'Sntiu it uN.. t ::?': ,
risuch other ac tion as may tie pr, rioeu � r►
„y l fit°
u , < y f 7
will not
be necessary, an, hat you
then action
;;r k
cords Lion
_t
z
S
Iyic Health Director
Fx✓:.i�d,y/2�,t°�,rd
- f�+, -F � gaff ;, � ,
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t;
rec or
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,,.�, yuya.� *t, �p�.. _� ; . _ ..,: a , . .. ?. t:r?:.a.,:t:Y ra tt. AZd'; >:_ x;�y.;a�s� �t :_,• ..
PUTNAM COUNTY HEALTH DEPARTKENP
DIVISION OF ENVIRONMENIAL HEALTH SERVICES
rPROPOSAL FOR SEWAGE DISPOSAL SYSTEM REPAIltJ
OWNER'S NAME
SITE LOCATION
PHONE
s
TM#
PERSON INTERVIEWED PCHD Cag3laint #
Name & Relationship (i.e, owner,tenant, etc.)
DATE TYPE FACILITY
PROPOSED INSTALLER PHONE • vlOKq
REGISTRATION #
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.
Proposal approved lI— Proposal Disapproved
Ins r s ignature & Title Daty
Proposal amroved 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' 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 TITLE DATE
'PIES: White (.FCiD); Yel.lcw Main HE); Pink (Pipliaint)
i
04,*
��
1�•
�I.
__ / r�
J r /.
Proposal approved lI— Proposal Disapproved
Ins r s ignature & Title Daty
Proposal amroved 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' 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 TITLE DATE
'PIES: White (.FCiD); Yel.lcw Main HE); Pink (Pipliaint)
; 11011IC4
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