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Robert J. Bondi „ r Cris Dellaripa
County Executive Septic Repair Inspector
Edward A. Barnett Michele Palermo
Watershed Information Coordinator Office Manager
PUTNAM COUNTY SEPTIC REPAIR PROGRAM
100 Rte, 312
Bldg. #4
Brewster, NY 10509
Date:
PCDOH
Attn: Michael Budzinski
1 Geneva Rd.
Brewster, NY 10509
Dear Mr. Budzinski;
We wish to report that the following job: Name ec. y
Address e PclT.
Tax ID# 3 6 p 3,q
has been completed as per the approved drawings.
As -Built Attached: Yes C No
Signed
CC: Dan Shedlo, P.E.
Telephone: (845) 278 -8313
Fax: (845) 278 -2318
/000 Ge
PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
PROPOSAL FOR SEWAGE DISPOSAL SYSTEM REPAIR
YES NO Internal Use Only
❑ ,_., Repair Permit issued in last 5 years ❑ Not in Watershed
❑.., / Lg' / Repair within Boyd's Comers, W. Branch or Croton Falls Res. ❑ Delegated
Lam' ❑
Repair within 200 ft. of a watercourse or DEC - mapped wetland ❑ Joint Review
SITE LOCATION 7 L Pa`'i"fi��,�. #
OWNER'S NAME ��, E'„ \ �, PHONE # 7C7 J 13
MAILING ADDRESS �j,r e
APPLICANT P C S
Name & Relationship (i.e., owner, tenant, contractor)
DATE T-2 0 0 6 FACILITY TYPE , ; PCHD COMPLAINT #
PROPOSED INSTALLER J6 �.. PHONE #
ADDRESS REGISTRATION /LICENSE #
Proposal (include a separate sketch locating the house, property lines, all adjacent wells within 200
feet of repair and the location of existing and proposed trenches)
NOTE: Repair must be in same location and of same type as original sewage disposal system.
Different location and proposed pump systems will require submittal of proposal from licensed professional
engineer or registered architect. `
- 1, . /c- 1 ` In e- Lo % U O 0 te9-a-
I, as owner, or reported agent of owner agree to the conditions stated on this form
SIGNATURE (_�Js: TITLE _
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
d. System description (e.g., 1250 gal. Concrete septic tank, etc.)
e. Installers' name and phone number
3. System repair to be performed in accordance with the
above proposal and conditions.
t X - Proposal Denied
NWAMO
Inspector's Sftmr6ylb & Title 11 Date
COPIES: Whi (PD); Yellow, o I); Pink (Installer), Orange (Applicant)
PC -RP 99
Rev. 8/05
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Robert J. Bondi Cris Dellaripa
County Executive Septic Repair Inspector
Edward A. Barnett Michele Palermo
Watershed Information Coordinator Office Manager
4
PUTNAM COUNTY SEPTIC REPAIR PROGRAM
100 Rte. 312
Bldg. #4
Brewster, NY 10509
Date: /1/2- 0 /�
PCDOH
Attn: Michael Budzinski
1 'Geneva Rd.
Brewster, NY 10509
Dear Mr. Budzinski;
We wish to report that the following job: Name M G- K r, eG k
Address `%T Sam f-/-� (� e 17� Pad
Tax 1D#
has been completed as per the approved drawings.
As -Built Attached: Yes No
Signed
CC: Dan Shedlo, P.E.
Telephone: (845) 278 -8313
Fax: (845) 278-2318
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JOEY MCKNE�ELY
DEING
%lOWN ON
FUV MM "TENTH MM OF PUTNAM LAKE' PLED MM PLEP ON 10/ 30/ 31
tV 1I YIV (X- rAtl R5(gN IN b
LiINiW1 CO., N.Y.
SCALE: I" - 20' ALJGLryr 16, 2004
COPYWW @ 2004 TElW 9MRZWOWF W A IN5. AI-L Mair51i W vEn
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