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36.48 -2 -26
BOX 18
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0 -d%ra- -1 Ir'ifT r Tob - . - k* -
02070
OWNER'S NAME
SITE LOCATION
MAILING ADDRESS
PUTNAM COUN'T'Y HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
PROPOSAL FOR SEWAGE DISPOSAL SYSTEM REPAIR
PHONE ,,!9 7T — 767_
THO /Yq - .933 - OF
PERSON INTERVIEWED PCHD Canplaint #
Name & Relationship (i.e, owner,tenant, etc.)
DATE TYPE FACILITY 1qeS' 1 d e /ice-
PROPOSED INSTALLER, iCC� PHOI� c�l 9 -lOG 9
Pro (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 fran licensed professional engineer or
registered architect.
Proposal approved
Inspector's
Proposal Disapproved
I
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 canponents 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 reported agent of owner agree to the above conditions.
DIES: H Ute (MV; Yells w (T,,vn ED; Pink Lk#icant)
TITLE �jJ DATE -020 -Cl i`
!
i.
s
i
a�
y
A
House
A
Por.ch:�
f
4 A B
0 --- Septic Tank
�-- -Pump Chamber
i
i
i
E-- -Stone vall
i
3'x 65'
P
A
i a
3'x 65'
o
i 31x 65' '
C=ain..Pra&n..
Stephen Pacuk
21 Cameron Rd.
Brewster, N.Y.
R -26 -94
4 -11 -94
Bottge.Septic,
'Sodom Rd.
Brewster, N.Y.
A
Tank #1
27'
11216
Tank #2
31'
16'
Pump Pit
38'
20'
Box #1
46'
63'
Box #2
51'
67'
Box #3
5716"
72'
Bottge.Septic,
'Sodom Rd.
Brewster, N.Y.
CAMERON
ROAD
/0000'
O
Qi
459 •,.,,� I c
25.2
Lot 832
- toe •fca
h 1 I r
{� c
v Q ' _L co/7c. c.
�l Plo
Vi D
-Y :4 of 839
2.0
- . Lot 840
_Y n ,', L l H ,n �6k,�3 �,•
'.) �• •••• •� Al C4.1 � 3 �6 �`''- � Lot 841
S53034'W"W 100.00'
Certified correct to Mldcoast Mortgage Corporafiw
and to the Intercounty Abstract
7h-ls Is to certify that th/s survey was completed
on LLacelrber /8,1992, and this mop was completed
on December 19,1992•
At Y State L ic. Surveyor
Filed /WGP A
.
Lot - 833 thru 837 h7cl ond AV7thru 900 ne
Lot 896
/00.00
�4
Lot 841
I
Lot 842
suR vE Y OF PRoPER r Y
Prepared for I
Title - imp of Putnam L GKO 9 FRA / KES PA C UK
STEPHEN 4 i1lo.- I49 MUM
Prepared Dec 1992 TOM OFPATTERSOPI
Rjfwn Co.. NY
Scale 1 =20'
L.DUNCAN OLMSrEDJR
South Salem" N Y
10590