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BOX 18
01954
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WA
01954
PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
PROPOSAL FOR SEWAGE DISPOSAL SYSTEM REPAIR
OFFICIAL USE ONLY
SITE LOCATIONufiy�. �o /`T� �ic=� /l-�O� TM# -3 � 30
OWNER'S NAME 7 Y PHONE
MAILING ADDRESS 7 y,r-a �'� �i e �� r, e !�� f� Prsa•„ .2�
PERSON INTERVIEWED 7 G PCHD Complaint #
ame & Relationship i.e., owner, tenant, etc.
DATE
4191
TYPE FACILITY
ALLER %`D --r 6e;, ,e, 4-1.o //o e PHONE
ADDRESS REGISTRATION#
ro a (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 as owner; -or reported agent of owner agree tv conditions stated on this form.
SIGNATURE / ,-__'' GD r✓-�,G /Yi�� a TITLE 7 " S /����•-
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 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 performed in accordance with the above proposal and conditions.
Proposal approved
Inspector's Signature & Title
COPIES: White (PCHD); Yellow (Town BI); Pink (applicant)
PC -RP 99ML
DATE
LORETTA MOLINARI
Public Health Director
DEPARTMENT OF HEALTH
1 Geneva Road, Brewster, New York 10509
Environmental Health (845) 278 - 6130 Fax (845) 278 - 7921
Nursing Services (845) 278 - 6558 WIC (845) 278 - 6678 Fax (845) 278 - 6085
Early Intervention/Preschool (845) 278 - 6014 Fax (845) 278 - 6648
SEPTIC REPAIR FACSIMILE
TRANSMITTAL TO DEP
To: Danny Shedlo, P.E
From: Putnam County Health Dept.
PCHD Repair # k -/43 - 0 cf
Fax #: (914) 773 -0343
Date: & g e-
Pages: Z-1`
.._:.... - .. �i1,`� ,/✓.�..�,'�: X05 �`s_�� -�� . = �._l"�� �,.���Q!. - �-- _ � _ . _ . _._
PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
OFFICIAL USE ONLY
tom/
s vim. i � ro
SITE LOCATION loa&,, �o �. /'�lr...��0` TM# 30— _ 1�
OWNER'S PHONE
MAILING ADDRESS 7 `/,r- �i "�S -�`e /� al r „r p, /�a7�1l+PrJO�I► .�i5•'
PERSON INTERVIEWED %G •yi PCHD Complaint #
Name & Relationship i.e., owner, tenant, etc.
DATE Z / C/oy TYPE FACILITY
PROPOSED INSTALLER. �`D •yr C� 5.o // ke PHONE
ADDRESS REGISTRATION#
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.
- �° C> r�►�i� o .l rsi l �� /d J w jaw P v�e S t°`✓�/`�
I, as owner; or reported agent of owner agree t conditions stated on this form.
SIGNATURE ,J� d'�`'' G1 lo�,G .G TITLE 7 r'
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 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 performed in accordance with the. above proposal and conditions.
Proposal approved_
Inspector's Signature & Title
COPIES: White (PCHD); Yellow (Town BI); Pink (applicant)
PC -RP M&
Z
DATE