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Home My WebLink About2072DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 36.48 -2 -29 BOX 18 02072 7 'T� ' '. ETA - Iwo 1 02072 R G�� 7A PUTNAM COUNTY HEALTH DEPARTMENT DIVISION OF ENVIRONMENTAL HEALTH SERVICES Rill PROPOSAL FOR SEWAGE TREATMENT SYSTEM REPAIR Internal Use Only PERMIT # U h6 / Repair Permit issued in last 5 years U,fVot in Watershed ❑ Repair within Boyd's Comers, W. Branch or Croton Falls Res. EZ Delegated ❑ Repair within 200 ft. of a watercourse or DEC - mapped wetland ❑ Joint Review SITE LOCATION Rhtr-CC/It�l M. TOWN f Va`�TM # OWNER'S NAME 10mo ' - f6fe;;L. PHONE # MAILING ADDRES..,,S--,,ii,�j- � ar� t Gfei w ei /� IOS09. APPLICANT WWAQ✓1 M(: nAIW Name & Relationship (i.e., owner, tenant, contractor) DATE f p I id 'A- FACILITY TYPE PCHD COMPLAINT # PROPOSED INSTALLER 0"'Pt fefc)�- . PHONE # (01 i`TJ 'C 3cS� 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 system) NOTE: The Department may require submittal of proposal from licensed professional depending on the Viure and extent of the repair. Zw v-hG -fe-4x-,1 o y 05, vic'r 60,01 611) b is &Co -n6f s . S) A' t nA u::4 13, I, as owner,agree to the con n On this form SIGNATURE TITLE DATE / / L% (owner) I, these tic inst e ,4gree c e conditions of this permit for the septic system repair _ SIGNATURE TITLE f/ �5da1��T DATE (� l (installer) Proposal approved he f wing conditions: 1. Procurement of ny ToA Permit, if applicable. 2. Submission of as built repair sketch by the septic system installer within 30 days of the repair, in duplicate showing: a. Owner's name, Site Street Name, Town and Tax Map number b. Location of installed components tied to two fixed points c. System description (e.g., 1250 gal. Concrete septic tank, etc.) d. Installers' name and phone number 3. System repair to be performed in accordance with the above proposal and conditions 4. The proposed SSTS repair is considered a best fit design and there is no guarantee to the duration at which the completed SSTS repair will function. 5. No completed work is to be backfilled until authorization to do so has been obtained from the Department. INTERNAL USE ONLY Proposal Approved Proposal Denied Q In pector's Signature & Title Date Exp ration Date Repair proposal is in compliance with applicable codes Yes No 0 COPIES: PCHD; Owner; Installer PC -RP 99ML Rev. 2/07 n ALLEN BEALS, M.D., J.D. Commissioner of Health - Director of Environmehial Health DEPARTMENT OF HEALTH 1 Geneva Road, Brewster, New York 10509 Phone # (845) 808 -1390 Fax # (845) 278 -7921 CERTIFIED MAIL RETURN RECEIPT REQUESTED OFFICIAL NOTICE OF NON - COMPLIANCE MARYELLEN ODELL. . . County Executive PLEASE RETURN CORRESPONDENCE TO: Woodland Manor LLC NAME: Gene D. Reed Omar Perez TITLE: Principal Engineering Aide 188 Haviland Drive PHONE: (845) 808 -1390 Ext. 43261 Patterson, NY 12563 DATE: November 3, 2014 YOU ARE HEREBY NOTIFIED of non - compliance with Article III Section 3.2A of the Putnam County Sanitary Code as stated below. " ... No person shall undertake to construct, or allow to. be constructed, any SSTS modification or repair to a SSTS without first having obtained the written approval for such system from the Director /Commissioner." The SSTS at- l.!• Rhinecliff Road, Patterson, NY 12563 -was repaired without -a-repair permit as-- witnessed by a representative of the Department on October 22, 2014. Violations of this kind will make you liable for penalties provided by law, including prosecution on a charge of committing a violation punishable by a fine or imprisonment, or both such fine and imprisonment as prescribed by law, in addition to such other actions as may be prescribed. Sincerely, Gene D. Reed Principal Environmental Engineering Aide GDR:cml r r Pataam County Department of SesM Division of Environmental Hedlh Services site sp N SSi'8 Repair- - Final S. inon Date: r �.�:. _ Street 'on: j Z 'Z6 i „-& ' , Owner.. `re (e, z. Town• Rep* Permit #: ”' TM # 36> IM RFSI Rev-01 1312 PUTNAM COUNTY HEALTH DEPARTMENT. G 1 DIVISION OF ENVIRONMENTAL HEALTH SERVICES PROPOSAL FOR SEWAGE TREATMENT SYSTEM REPAIR s u —YES �Y ' N011` Internal Use Oniv PERMIT # R-' i y - I `I Li B Repair Permit issued in last 5 years of in Watershed ❑ W Repair within Boyd's Comers, W. Branch or Croton Falls Res. W Delegated ❑ Repair within 200 ft. of a watercourse or DEC - mapped wetland 0 Joint Review SITE LOCATION ��}' �111 red %�i W. TOWN : �`-�TM # Wf Z OWNER'S NAME nmov ' Y�2 PHONE # 11 35 MAILING ADDRESS ��__ APPLICANT V Name & Relationship (i.e., owner, tenant, contractor) DATE tO 16 f w FACILITY TYPE PCHD COMPLAINT # PROPOSED INSTALLER ln.•r y Tgfc).�_: PHONE /> ADDRESS AQV &lthr-d IX It ^VT REGISTRATION /LICENSE # � • Proposal (include a separate sketch locating the house, property lines, all adjacent wells within 200 1 ! ` l� feet of repair and the location of existing and proposed system) NOTE: The Department may require submittal of proposal from licensed professional depending on the ►nature qnd extent of the repair. I . i 01 6),tr tnA I, as owner,agree to the co I n this form SIGNATURE TITLE DATE AV lx�1141 (owner) ti 1, the septic inst. . Ee i` f�e conditions _of. -this perrtiit.for the septicsystem:repait TITLE SIGNATURE (Installer) DATE /0//4M I. Procurement of k(ny To% n Permit, if applicable. 2. Submission of as built repair sketch by the septic system installer within 30 days of the repair, in duplicate showing, a. Owner's name, Site Street Name, Town and Tax Map number b. Location of installed components tied to two fixed points C. System description (e.g., 1250 gal. Concrete septic tank, etc.) d. Installers' name and phone number 3. System repair to be performed in accordance with the above proposal and conditions 4. The proposed SSTS repair is considered a best fit design and there is no guarantee to the duration at which the completed SSTS repair will function. 5. No completed work is to be backfillo until authorization to do so has been obtained from the Department. INTERNAL USE ONLY Proposal Approved Proposal Denied ❑ g In pector's Signature & Title Datef Exp ration Date Proposal Repair ro h applicable codes Yes l� No O p p Is In compliance wlt COPIES: PCHD; Owner; Installer PC -RP 99ML Rev. 2/07 _. i i NjojshaJe� se Ptia Alew a1, Pi,,-- s +,' k . .5ctwLe" Clj v:':g1�24: � 7'cL�'lk 17 Z hinecl',O RD ce�ster �3 y .l 05 ®1 GdS4Gct R Qe 4 t46le Cone e. PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES DESIGN DATA SHEET - SUBSURFACE SEWAGE TREATMENT SYSTEM Owner: F,6-779 7 Located at (street): Municipality: -F Address: TM# Z' a2-9 Watershed: Ows—i SOIL PERCOLATION TEST DATA Witnessed by: Date of Pre - soaking:_ Date of Percolation Test: Hole No. Hole depth (Inches) Run No. Time Start —Stop Elapse Time (min.) Depth to water from ground surface (inches) Start - Stop Water level drop in inches Percolation Rate min/inch 2 3 5 I l i : 11 re _ ��. IF IA- 4 5 1 2 3. 4 5 1 2 3 4 5 lvotes: 1. Tests to be repeated at same depth until approximately equal percolation rates are obtained at each percolation test hole. (i.e., < 1 min for 1 -30 min/inch, < 2 min for 31 -60 min/inch): All data to be submitted for review. Z Depth measurements to be made from top of hole. Form DD -97, pg t of 2 TEST PIT DATA DESCRIPTION OF SOILS ENCOUNTERED IN TEST HOLES DEPTH HOLE #_L_ HOLE # HOLE # HOLE # HOLE # G.L. 0.5' '!5, 1.0' 1.5' 2.0' m, 14a o4 2.5' 3.0' 3.5' 4:0' '"7 4.5' Se Go 5.0' 5.5' 6.0' 6.5' - 7.0' 7.5 8.0' 8.5' 9.0' 10.0' Indicate level at which groundwater is encountered Aza Air. Indicate level at which mottling is observed A &4 Indicate level to which water level rises after being encountered -� 3 � Deep hole observations made by: Date /o Design Professional Name: Address: Signature: Revised July 2013 Design Professional's Seal J' a Sheet —k_of�_ *. PUTNAM COUNTY DEPARTMENT OF.HEALTH. ,_.r. �.- . �- ��,.., n,=. J�IVISTO�I' 7' tCi�+"° EN�iI"li'C�NPVi�"I`7T�'Hl��`1"H : �O�S' �,.. �. ::,.....�,�...a- ,.,._.,...v,._• ......o:.._a �.e,.� FIELD ACTIVITY REPORT r" Street Town State Zip PERSON IN CHARGE OR INTERVIEWED: 61weirr BfY'eZ Name and Title TYPE OF FACILITY: FINDINGS: Ste` fA i> il -- cJelJ INCPFC'TQR! TFI Signature and Title RFPCIRT RFC'FIVFD RV• I acknowledge receipt of this report: SIGNATURE: 02/96 Rev. PUTNAM COUNTY DWARTMENT OF HEALTH DIVMON OF ENVMOPMU 'AL E09ALTH SERVICES AMWonffadoommdbeb&mVL*&dpieripasysdkedaft..' Dae: 110-Zq E*gigeelr ® Firmacr c�rxz l ,Q/ YQ12,01 phone #• mn Coutacd: m r r r l c ❑ New Construction 12(ftak Program ❑ Addi$ion Proglram on: ❑ Deep )2tem ❑ Test Twu; , !mow �. ;� � ,- !]6't 'faxM&P# -. 36.Yl -k -a,q Subdivisim: Owner: Q Pmject not within NYC Watershed IACt #b: ❑ ! 7 prepasedl MM wftb the dnftW bade of West Branelt, Craton Falls, or Boyds Corner reservoirs. 0 5, Proposed SRS Wain MW ho of& rawrrair, raervair A= or eau ftl calm ❑ 13' Proposed S5 n widtin X00 Pat of a WxWraeum or a DZC wetland. 0 2 rropoxJ ors dedp Bow gnmkr than 1WO pliandday or MDBS ]permit rat W" d. 0 [2 Proposed SM for a Colo=creial Proje&. it is the rtsgoagaft of the deslgst prom to provide Me above informaflon prior to soil testing. This Deparbont will determine the MYCDi P project stns (Joint or Ddqpted) based OR the raspowe. If you an,swan d ya to any of tfre gaestimm MYCDEP mnst was the aril testa_ This ngwrtment will wardlate a mwtuaW mntable dw Pur field testing will, the Defta Profession and N YCDEP ft a preint ]yes been determined to be DehgaW bated an the above rsspwm and then aabseguwd W,or a#ion indicates WDEP i8 t Aired to wjWm stet soil tests, it quill be the We responsibility of the deWp professional to schedule re- wKnessing of ,tie sail testing with NYCDiP,P. FOR COUNTY USE ONLY VATZ _� �� %YAK`. COl�l� RA ,,'for Meld te$tAdy 1010014 mow vow" _�� i ••. tip. �. Mw 27- 4Y An All - t5 9p I I oq L7-:1D N ----------------- ......... ■ __; SHERLITA.AMimR M11} •MS EA$� — , Commissioner of Health k LORETTA MOLINARI, RN, MSN Associate Commissioner of Health November 29, 2005 Louis Rivera 17 Rhinecliff Road Patterson, NY 12563 Dear Mr. Rivera: DEPARTMENT OF HEALTH 1 Geneva Road, Brewster, New York 10509 Re: Repair — Incomplete R- 317 -05 17 Rhinecliff Road (T) Patterson, T.M. 36.48 -2 -29 County Executive Upon inspection of the above referenced property it was noted that the septic system is failing. At this time the proposed repair submitted to this Department cannot be approved. This Department cannot approve the use. of seepage pits for any lots that did not previously.utilize one. Please resubmit�a proposal for a repair that is generally__of same- type -as-the exisfing--Pitase- note -that-due °to-the-f�h is�eparttneri�i that the septic tank be pumped out until such time that the septic system has been repaired. If you have any further questions, please contact me at (845) 278 -6130, ext. 2261. GDR: cw Sincerely, 0 4 _'_ - �) , r, ex Gene D. Reed Sr. Environmental Health Engineering Aide Environmental Health (845) 278 -6130 Fax (845) 278 -7921 Nursing Services (845) 278 -6558 Fax (845) 278 -6026 WIC (845) 278 -6678 Nursing Home Care Fax (845) 278 -6085 Early Intervention /Preschool (845) 278 -6014 Fax (845) 278 -6648 ��., -� - :�°.E�ItI?I3€A^�ai1�LI✓'R; R�;,1V�s; I�ti Commissioner of Health LORETTA MOLINARI, RN, MSN Associate Commissioner of Health November 29, 2005 Louis Rivera 17 Rhinecliff Road Patterson, NY 12563 Dear Mr. Rivera: ik # DEPARTMENT OF HEALTH 1 Geneva Road, Brewster, New York 10509 Re: Repair — Incomplete R- 317 -05 17 Rhinecliff Road (T) Patterson, T.M. 36.48 -2 -29 County Executive Upon inspection of the above referenced property it was noted that the septic system is failing. At this time the proposed repair submitted to this Department cannot be approved. This Department cannot approve the use of seepage pits for any lots that did not previously utilize one. Please - resubmit a proposal for a -re air that is generally of the . same type as the existing. Please note that due to the failure, this Department is requiring that the septic tank be pumped out until such time that the septic system has been repaired. If you have any further questions, please contact me at (845) 278 -6130, ext. 2261. GDR: cw . Sincerely, s2�� —0, Gene D. Reed Sr. Environmental Health Engineering Aide Environmental Health (845) 278 -6130 Fax (845) 278 -7921 Nursing Services (845) 278 -6558 Fax (845) 278 -6026 WIC (845) 278 -6678 Nursing Home Care Fax (845) 278 -6085 Early Intervention/Preschool(845)278 -6014 Fax(845)278 -6648 AD, MS, BONDI Uo�vjty E"kemwe V H8ALT.11i Ne'vv 'Ifttk 10509 P-Toy rib^r 9, 20 O5 Oat n da! I 201vy"HilltKoad 1 11 a b�' P,-3 17-05 xc: R(�Pa c mp. ".o Louis Rivera 17 Rhinecliff Road PtPatterson, T.M. 34A -2 -29 Dear Mr. Tyndalll:. I'1:6.•A of plans and other supporting documents subrnittcd at this time r-lative- to the abo,, i,--Yegardf-,d repair has be6n. c@nfipletcd. The following was not submitted �;vith.yovr Lk appli�; a, a_rtn," vving-tlhe, i -,n' t - h—o along with distances to,owners well and witliln 10T.'. to note all components that are included in the -pain revised to reflect the,above comments, this n--i!': evi P '..J't on will be �Jcl fL -If at esti on&, p 16ase contact me at (845) 278-6130, e,.-,t. ""2 Sincerely, Gene D. Reed Sr. Environmental Health Engineering, Environmental Health (845) 278-6130 Fax(845)278-7921 Nursing Services (845) 278-6558 Fax (845) 278-6026 WIC(845)278-6678 . Nursing Home Care Fax (845) 278-6085 Early I.nterventioa/Preschool (845) 278-6014 Fax (845) 278-6648 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 ❑ ❑ Repair within Boyd's Corners, W. Branch or Croton Falls Res. ❑ Delegated ❑ ❑ Repair within 200 ft. of a watercourse or DEC - mapped wetland ❑ Joint Review SITE LOCATION % TM # 3 6• 0- 2-2-I OWNER'S NAME a / �j�p� q PHO,,N /E,# Z 79 "� 06 MAILING ADDRESS 17 Xhlr'e C%/FC ,2d f kK , I Y APPLICANT Itu 6 Name & Relationship (i.e., owner, tenant, contractor) DATE // 1,521 10-!!r FACILITY TYPE �eCS, PCHD COMPLAINT # PROPOSED INSTALLER to /S �(/rrf PHONE # 2-7:9 -66 6 ADDRESS /-7 /� him E'G��- _ keaAf QGISTRATION /LICENSE # 0 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 I, as owner, or reported agent o ner agree to the conditions stated on this form SIGNATURE TITLE �juj�l t°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 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. Proposal Approved Proposal Denied Inspector's Signature & Title Date COPIES: White (PCHD); Yellow (Town BI); Pink (Installer), Orange (Applicant) PC -RP 99ML Rev. 8/05 DATE 006,14M PUTNAM COUNTY HEALTH DEPARTMENT DIVISION OF ENVIRONMENTAL HEALTH SERVICES PROPOSAL FOR-SEWAGE DISPOSAL SYSTEM REPAIR .. YES NO Internal Use Only ❑ EV Repair Permit issued in last 5 years ❑ Not in Watershed ❑ ❑ Repair within Boyd's Comers, W. Branch or Croton Falls Res. ❑ Delegated ❑ ❑ Repair within 200 ft. of a watercourse or DEC - mapped wetland ❑ Joint Review SITE LOCATION ` TM # _ di Q% OWNER'S NAME PHONE# �2%fr— 6)e, fZ• MAILING ADDRESS . %.Z "l�7e Zz7 .,/kmor.3 APPLICANT Injo Name & Relationship (i.e., owner, tenant, contractor) DATE oJ� FACILITY TYPE �� PC HD COMPLAINT # PROPOSED INSTALLER Vi S PHONE #2 21-- W 2 ADDRESS 7 Aavuf V EGISTRATION /LICENSE # q3 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. I, as owner, or reported agent of owner agree to the conditions stated on this form SIGNATURE ./ TITLE Proposal approved with the follow' conditions: 1. Procurement of any Town Permit, if applicable. 2. Submission of as built repair sketch in duplicate showing: a. Owners 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 rep' a'Vto be performed in accordance with the above proposal and conditions. Proposal Approved Proposal Denied Inspector's Signature & Title Date COPIES: White (PCHD); Yellow (Town BI); Pink (Installer), Orange (Applicant) PC -RP 99ML Rev. 8/05 DATE 4 at EXISTING WELL L2'X24' — LARGE SHED No tvNUK leo, ti 32'Ft FROM EXj[St'--`!'i4ELL 100.000 PROPOSED 6*x8` DRYWELL 80.000, RHIN,,KLIFFE ROAD BREtWSTER, NY js SMALL SHED -25!Ft FROM THE BACK OF THE HOUSE SEPTIC FIELDS APPROX. 7V VT FROM - NEIGHBORS'EXITING WELL 500 GALLON SEPTIC TANK !NEIGHBORS, VAST. WELL 109 ft fROM LOT LINE LOT LINE DISECTS 3 *Ft DIAMETER OLD WELL „s ..._ - jUHN:'KARELL -'Jt:. P.E. M.S. Public Health Director DEPARTMENT OF HEALTH Division Of Environmental Health Services 4 Geneva Road, Brewster, New York 10509 (914) 278 -6130 July 21, 1994 Mr. & Mrs. Dzubak Rhinecliff Road Brewster, N. Y. 10509 Re: Proposed Addition - Dzubak Rhinecliff Road, Putnam Lake (T) Patterson Dear Mr & Mrs. Dzubak, I have received and reviewed the plans for the proposed addition to the above mentioned residence. The plans have been approved as per plans bearing this Department stamp and dated July 18, 1994. 's addition represents an increase ih living area of less th 15 . Therefore, based on the information submitted, the above me ned addition is approved with the following conditi-ons: 1. The total number of bedrooms must remain at 2 without prior approval by this Department. 2. The area of the existing sewage disposal system, and its expansion area, must be maintained. 3. All plumbing fixtures must be replaced or updated with water saving devices, i.e., low flush toilets, restrictors for shower heads and faucets, etc. Approval is granted for sewage disposal only. Any other permits or variances required are the responsibility of the applicant and the jurisdiction of the Town of Patterson. If you have any questions, please contact me at your convenience. Very truly yours, � /?/lid_ -- •- -:i• �� -- ��r� --� - 1 am W� 11 Hedges Senior Public Health Sanitarian RM:jh cc: BI (T) Patterson FORM: STAMPED ADDITION 8 H OkNER' S NAME 4 SITE LOCATION MAILING ADDRESS PERSON INTERVIE DATE PUTNAM COUNTY HEALTH OF ENVIRONMENTAL HEALTH SERVICES 19 h/ /9_.- C %� (i.e, owner, 4d • 9 19 (, , �e' are 5,p5 PCHD Catiplaint # Rill b, WLO-• 1 TYPE FACILITY _ PHONE REGISTRATION # ' U 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. Proposal approved Inspector's d+ Proposal Disapproved ture &? Title with the following condi Da 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, of owner agree to the above conditions. SIGNATURE TITLE POW DAT E .U. 11 Mite (PSI)); YeU w (Ttkin ED; Pink (AppUamt) PUTNAM COUNTY HEALTH DEPART - _ .DIVISION OF EWIRONMEWAL HEALTH, SERVICES :TV -.R �; -s•T. �: y �._.. v.. - - .�.n�.. .. .... . .. may'... -.nom :•.�.: ii.�+: •.. ..� ...r. y. .v •M:':....:R �. -��. -v - � - _r.._ .. 225 -0310 PROPOSAL FOR SEDGE DISPOSAL SYSTEM REPAIR OWNER'S NAME (1 err -t KaL�42ffl aW,I'd PHONE �'l y 27g ? u 61 SITE LOCATION C �, W MAILING ADDRESS 1- f. (i PERSON INTERVIEWED PCHD Camplaint # Name & Relationship (i.e, owner ®tenant, etc.) DATE TYPE FACILITY PHONE 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 Pro 1 appr ed Proposal Disapproved Inspector's Si tune & Titljb-6�1. 'e. Date Ox QA-ft 0-0 Proposal approved with the following conditions: ..45--o�, -a v � 1. Procurement of any Town permit, if applicable. 5 w , 2. Submission of as built repair sketch in duplicate showin� ro� 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 dryw ells 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. SIGNATURE TITLE DATE Z 1'S J/ 0�: Wine (KED); YeUcw ( HE); a Pink (Applicant) n adK P:pe_ LLO WackC LoMQ�e,�2e% cewNoVts Ac,e. \mots 5\jr � - - -- GraAe_ ��..� 1erng o� 4 ?ecQx 22' \c>n (T-V1 -5aave. kevv�.Vh A1ber� -� Kq v%ka -ern Garr -,o