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PUTNAM,OOUNTY HEALTH' •
DIVISION OF i iLTH
PROPOSAL FOR SEWAGE
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MAILING :ADDRESS ' ?.q
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PROPMED DST*a"L t:�_ PHWE CA
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w-REGISTRATION # N, 4.
lodating q_jacen
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0 -.,.,pame type 'as original sewage-,�
N=-. Repair must,',,be sairile- lbCatkhl', W.
1;Different 1
6cation pay:re qui
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suhUitt - ,,frcm licersed X
ess
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Proposal approved Proposal 'Disapproved
njspe&t:qt1,s;jSi4rAture -&-`.Tqitle: lA
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P
roposa COM
with the fOjjOWin4
1. r Pro re of any.' Totem permit, if appFl ble,
2 ip
on of --"�'built repair sketch" te showing:
Owner's name
.4 T" Map number. Sitd St
XeP
'F _tr, Nam,. Town W
ts (eL h' S).
g
cano.
onents tied two fixed poin
location of installed l
septic tank, t 61 diem. x 0 deep 'on,.;;'(b';.., 1250 gal.,Cdhcrete
stem description
foot + gravel).
surrounded' rjxu� :cm
Ile
e. Installer's name and n
3. System repair to be perf=8� ,, n accordance with - the above proposal conditions.
as erif or P10
g
oi'76i�& -agree to the,,above conditions.
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PUTNAM COUNTY HEALTH DEPAR'IMENr
_....DIVISION. OF ENVIRONNEN1AL HEALTH_ SERVICES
225 -0310 .. _
PROPOSAL FOR SEWAGE DISPOSAL SYSTEM REPAIR T 40 V ,- Q1 . `n
5 A/
O%1M ° S NAME Z. PHONE :ZZs zM-2,
SITE LOCATION���
MAILING ADDRESS .5',47a-r,�
PERSON INTERVIEWED PCB Complaint #
Dame & Relationship (i.e. ownergtenantp, etc.)
DATE TYPE FACILITY
PROPOSED INSTAT,T,F.R PHONE
Proposal (include sketch locating all adjacent wells)s
NOTE: Repair must be in same location and of sage type as original sewage. disposal system.
Different location may require submittal of proposal fram licensed professional'enginee: or
registered architect.
% rl?p, TA 9
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�= AMW
Proposal apL)roved
s
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Proposal approved with the following.conditions:
to Procurement of any Town.peYmit, 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 fined points (e.g.,house corners).
d. System description (e.g., 1250 gal. concrete septic tank,, three precast 6' diem. x 61 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 a ent of owner agree to the above conditions.
SIGNATURE ` TI= DATE
TEAS: V&te (FCD); Yellc w (7+n ffi) ® Pink (.Appliaant)
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Q A #6 HIGHVIEW DR. RMEL, N.Y. 10512
12- -
INSTALLED BY:
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BOTTGE SEPTIC, INC.
SODOM RD.
BREWSTER, N.Y. 10509
914).279 -6069
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PUIMM COUNTY.. HEALTH DEPARMU
\d' IVISION OF ENVIROAL'HEALTH SERVICES
225- 0310
PROPOSAL FOR SEWAGE DISPOSAL - SYSTEM REPAIR
46
SITE IC' 6 ION �}ce���, v ►� ho ` TO
MAILIIgG ADDRESS D"M-0,
PEEiSOD1 IN'I'EftVIEh1ID ObU11�/tJ PQ� Complaint 9
Name & Relationship (*i.e,, owner,tenant, etc.)
DATE Y,/� TYPE FACILITY �y IM_4� A& f se4
(/
PROPOSED INSTALLER 67e0j-g 1f, 5A1P k9_7 � . iU6F9 4 a1ja f S kc]!� PHONE. cA 7 q -- '7 39.S'
Proposal (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
Proposal Disapproved
to
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 ca ponents 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
OOPgS: phi ); YeUc w (M:kn HD; Plink (.Applicant)