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BOX 16
01728
tuo Re ou's
PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
OFFICIAL USE ONLY
2 - —
SITE LOCATION TM#
OWNER'S NAME PHONE 7533
MAILING ADDRESS�(� 2i- ZZ l�,�sfr:ri
PERSON INTERVIEWED PCHD Complaint #
ame & Relationship i.e., owner, tenant, etc.
DATE TYPE FACILITY
PROPOSED INSTALLER ,-p �, �,u,r� PHONE � • !,9
ADDRESS mil' sc (,,; - REGISTRATION# W, (14 - Iq
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.
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Gx l( 1� �'-�pezu l7�72� S'(�' j '� � � 7��C(r� i )2 al J)2[ i.rl° Alh. ► �VC -t;M 1
Ae6h , CA-mir d -&.V 1%a AT Q z, =, .
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1; as owner, -or mpo ted agent of'ovnYer agree to dne c;ondit otis'siated on this form.
SIGNATE t _
UR TITLE 7
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
DATE %U - 2-6- ' 2-�Zr
b. Site Street Name, Town and Tax Map number.
C. Location of installed components tied to two fixed points (e.g.,house comers).
d. System description (e.g., 1250 gal. Concrete septic tank, three precast 6' diam. X 6' deep
e. Installers' name and number.
3. System repair to be pe ormed in accordance with the above proposal and conditions.
Proposalapproved
fw
Inspector's Signature & Title
COPIES: White (PCHD); Yellow (Town BI); Pink (applicant)
PC -RP 99ML
3
leg 5—
DATE
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LEGEND
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PREL I M I NAF
DISPII1m AREAS .••••••..•••.•• ME'TIMB LINE AM 3000L ��..
OAMEASNIP -� oEYELwm LOT MAW
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R-AT
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SPECIAL DISTRICT �'- - °- scum DIMMS104 Ims1
- SPECIAL DISTRICT LINE
TOWN OF PATTERSO
- -F CALCULATED AREA 2.34 AC. CAL
sanol o1sn11cT LIME Smi VISUAL WIO
PAAT Oi' PARCEL B0IADARY �. -- »
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PAM NUA6Ep
45
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PUTNAM COUNTY, NEW YOD
AZ Z
CA
14
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(UCH 'P' Cl
P C O PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
PROPOSAL FOR SEWAGE DISPOSAL SYSTEM REPAIR
Q ... OFFICIAL USE ONLY.-
SITE LOCATION F Crlttf� Q, �.r y TM #�
OWNER'S NAME PHONE _ /(; iii 7y13
MAILING ADDRESS -L 2t)6A i!r 22-
PERSON INTERVIEWED PCHD Complaint #
ame a ations ip i.e.; owner, tenant, etc:
DATE TYPE FACILITY
PROPOSED INSTALLER 17u;' 1 PHONE 7r
ADDRESS 1 506x.,,:, Ca; ` So r ;'N it-, - ;mnz',. REGISTRATION# .: C yct .A
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
S-,Or z -Aols. -C' c E"W s r
Ct TA7, A, .a.S"rl1 466 a2I J'A <6 ? AT)
C !CPC !3' i�a S' �,.L Y�•A►” i it r,� AT _6-
I, �.° QF,kmer, o rcpcecd'&&, -a` cl ow7ek•alit' e.W the :,CoriditibnS stated. on this•form.
SIGNATURE l:( C1 tc°�' f �1 TITLE �tc DATE /U
Proposal apFroved with the following•condit go &-,
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 comers).
d: System description (e.g., 1250 gal.' Concrete septic tank; three precast 6' diain. X 6' deep
e. Installers' .name and number.
3: System repair to be performed in accordance with the above proposal and conditions. ,
Proposal approved_ - - -
Inspector's Signature &Title DATE
COPIES: White (PCHD); Yellow (Town BI); Pink (applicant)
PC -RP 99ML
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