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PUTNAM OOUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
225-0310
-PROPOSAL FOR SENAGE DISPOSAIi"SMW
6? c-4,
OWNER'S NAME JOHN & DOROTHY FELL PHONE 278 =9656
SITE I=TION. 7 HERMITAGE RD BREWSTER, N.Y. rnq 31-3-5
ADDRESS
lots 126 thru 130 -
MAILING
PERSON INTERVIEWED PCHD Caqplaint #
Name & Relationship (i.e, ownerrtenantr etc.)
DATE TYPE FACILITY
PRoposED INSTALLER BOTTGE SEPTIC,. INC. PHONE 219-6069
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.
toposal approved with the following conditions:
1. Procurement of any Town pexMit, if applicable.
2. Suhnission'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 canponents tied to two fixed points (e.g.phouse corners).
d. System description (e.g., 1250 gal. concrete septic tank, three precast 61 diam. x 61 deep
drywells surrounded by one foot + gravel).
e. Installer's name and number.
3. System repair to be perfomed in accordance with the above proposal and conditions.
1, as owner,, or reported agent f owner agree to the above,conditionse
SIGNATURE TITLE
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