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631- 589 -8100
36.41 -1 -25
BOX 18
02044
SITE LOCATION
.�( OWNER'S NAM]
MAILING ADDR
PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
PROPOSAL FOR SEWAGE DISPOSAL SYSTEM REPAIR
OFFICIAL USE ONLY
78 -O
PERSON INTERVIEWED PCHD Complaint #
—flame a ationsmp (i.e., owner, tenant, etc.
DATE, &od TYPE FACILITY
PROPOSED INSTALLER
,._ Affliviva
•
0 0 (include sletch 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;-orreported agent o evagree to the conditions stated on this foriii:
SIGNATURE TITLEl DATE
RLqnsal =roved with 1 con-ditionse
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
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 99U L
Z! Q'
DATE
Clark
October 2004 52.1 Lake Shore Dr
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Patterson NY
Tax map # 36.41 -1 -25
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Permit # R 278 -04
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EXCAVATIMU CONTRACTORS
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Permit # R 278 -04
4
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EXCAVATIMU CONTRACTORS
84v- 279 -8809
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PUTNAM COUNTY HEALTH DEPARTMENT
_ DNISIQN OF ENVIRONMENTAL HEALTH SERVICES
OFFICIAL USE ONLY
�a-�g -a
SITE LOCATION 4e - CL.i" TM#
OWNER'S NAME .��dZ Ors r. OYHONE
MAILING ADDRESS 1&-&iA43 r le-f /
PERSON INTERVIEWED 1,� ¢ ha uQ, /% OA//0 el' PCHD Complaint #
ame a atlons p I.e., owner, tenant, etc.
DATE , f y TYPE FACILITY ��-S /'arch c
—T _
PROPOSED INSTALLER
)NEZ22 �' �
TION#
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.
I, as owner, or reported agent o er agree to the conditions stated on this form.
SIGNATURE TITLE �/'G�
o ve wi conditions:
1. Procurement of any Town permit, if applicable.
2. Submission of as built repair sketch in duplicate showing:
a. Owner's name
s
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.
Proposalapproved
Inspector's Signature & Title DATE
COPIES: White (PCHD); Yellow (Town BI); Pink (applicant)
PC -RP 99ML