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36.39 -1 -21
BOX 18
02013
PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
OFFICIAL USE ONLY
12 Fair field Drive, Brewster, NY TM# 36.39 -1 -21
SITE LOCATION Gerald Dove
OWNER'S NAME _ G,e,-ald Dgyle PHONE 845 -273 -6933
MAILING ADDRESS same as above
PERSON INTERVIEWED G. Do le PCHD Complaint #
Name & Relationship (i.e., owner, tenant, etc.
DATE March 27, 2003 TYPE FACILITY pr; va j-P a nal > ; c,
T
PROPOSED INSTALLER J.Mantovi Excavating Inc. PHONE 845- 628 -4526
ADDRESS 485 Kennicut Hill Rd, Mahopac, NY 10541 REGISTRATION# 18 -03
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.
Y ;
I as owner, or reported agent of owner agree to the conditions stated on this form. ,.....__.
SIGNATURE. /' lrVt�. ' UIJ (� c^ TITLEC: ¢Q- DATE. L,/ Z" 3
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 991ML
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PUIXAM COJYNTY HEALTI-LDEPARTMENT
DIVISION:OF JNyJ'RONMENTAL HEALTH SERVICES
PROPOSAL FOR SEWAGE DISPOSAL SYSTEM REPAIR
OFFICIAL USE ONLY
12JdF1iyrfeia1d Drive,
SITE LOCATION Gera Br'--wSter, -`1"TM# 36.39-1-21
OWNER'S NAME -PHONE 643-217S-59:3-!
MAILING ADDRESS s;:;La,_- as above
PERSON INTERVIEWED G. Doyle WM PCHD Complaint #
g-kr)
Name a lationship (i.e., owner, tenant, etc.)
FACILITY DATE L"Iaxck�. 27 2003!� . .... . TYPE
PROPOSED INSTALLER J - MantL
Wi &\Cavatirig Inc. PHONE 845-1.328-4526,
;
ADDRESS 485 Kennicut Hill Rd, Matiopac, i� Y 1 0541 REGISTRATION# 13-03
Proposal (include sketch locating all adjacent wells):
NOTE: Repair must be in same location and of same type as original sewage disposal system Different locatioll
may require submittal of proposal from licensed professional engineer or registered architect.
L,-stali* (4) Rediargers witn cir..-1yC-1 unly..r R ;ly-coll-c-i oni F �1-
rc- location Ila, Closer t8 WCA- A',
__L_a's. owner, . �orreporied. agent of owner a0ee to the conditions stated on this form.
SIGNATURE , I V DATE ti
=r�SA — . TITLE(.,-I-r-
'Proposal approved the with th following conditions:
1. Procurement of any Town permit, if applicable.
2. Submission of as built repair, sketch in,d catesho showing:
pg:.
a. Owner's name
b. Site Street Name, Town and Tax Map number.
C. Location of installed componen� 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. Adlers' name and numbir.
3. System repair to be performed in 4'ccof i dance with the above proposal and conditions.
Proposal approved ">4_11
Inspector's- Signature-& Title
COPIES: White (PCHD); Yellow (Town BI); Pink (applicant)
PC-RP 99ML
A
DATE.,."..
MAHOPAC SANITATION SEPTIC; `INC-.-. ;r
Septic Tank Service
217 Kennicut Hill Road
MAHOPAC, NEW YORK 10541
628.4526 Joseph A. Mantovi
OWNE1
SITE
MAID
PERS(
DATE
PROP(
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.
Y,
1
Proposal approved Proposal Disapproved
Inspector's Signature & 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' diam. 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 repoS_tekaaent of owner agree to the above conditions.
SIGN - TITLE DATE
OPUS: Trite (PQI)> ; Yelkw (Tam HI); Pink (Applicant) .
1 ,.
PUTNAM C&N' Y DEPARTMENT OF HEALTH NO. 367 -93 -19
COMPLAINT OR .SERVICE REQUEST RECOR
TOWN
PATTERSON.
DATE
REFERRED TO
TAKEN BY
BH
TELEPHONE CALL
IN PERSON LETTER
CONFIDENTIAL
REQUEST FROM
Ira B#rnstein
TELEPHONE 251 -6915 W
ADDRESS
Fairfield & Lake Shore
Drive, Patterson
ENVIRONMENTAL HEALTH: Home Sewage Rodents Refuse Public Water Food Service
Migrant Camp Other
COMPLAINT OR REQUEST
!- lh.ite house on Fairfield Drive, septic problem.
Corner house. Gerald? .,L
ACTI Od T N BY
FINDINGS %��.1' .2 %� O S �✓��
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FOLLOW UP TNSPECZON (s)
DATE FINDINGS
DATE FINDINGS
DATE
PERSON NOTIFIED I—e, r�o " ---7
L
ESTIMATED TOTAL MAN HOURS SPENT
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