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02076
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From - CENTURY 21 845 279 5607. T -254 P.002/002
PUTNAM COUNTY HEALTH DtF'AK I MtN I
DIVISION OF ENVIRONMENtAL HEALTH SERVICES
A
YES NC
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SITE i_OCA N /,-r
OWNER'S NAME
MAILING ADDRESS
Intemai use OnN
Repair Permit Issued in last 5 years
i
Repair within Boyd% Comers. W. Branch or Craton. Frills Res.
Repair within 200 ft, of a, watercourse or C)tG napped wetlan
41- .iei OR= zy
Wes.
APPLICANT .
N
MA 4Z J
a e & Relatonship (i.e., owner, tenant, otrcor)
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PATE j.2 g FACILITY TYPE 7 ed ors Re 1e ,,cJ0CHD COMPLAINT #
PROPOSED INSTALLER dgrdiG% CyAIAad%n j _PHONE # FiV S
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ADDRESS A0, do-X. 5-3a Ye,, Al tr __REGISTRATION /LICENSE # PC A2 6
Proposal (include a separate sketch locating the house,! property tines, all adjacent welts within 200
feet of repair and the location of Watinig And proposed trenches)
MOTE: 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.
F -829
❑ Not In Watershed
Q Delggated
❑ Joint Review
#,'70i e YT ` d °—
I, as o r reported ant of o ner agree to the conditions stated on this form
t
SIGNATU I _ TITLE:
Pro sa roved w the follow condit g:
1. Pro ement 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; fled 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 nd conditio s.
P posal Appro Proposal Denied
I spector's Si re 8 itle Datt:
COPIES: White HD); Yellow v Sl); Pink (Instalier), Orange (Applicant)
PC -RP 99ML
Rev. 8/05:
DATE
M' BURDICK CONTRACTING, LTD.
1�6.< d9k 53'a
BREWSTER, NEW YORK 10509
(914) 279 -4152 L /c . iqt gc - /ol6
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ow Al EA 7 �sgtfw Repair 4S/oI'L- l
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1000 0.4
Conrowe� dY
SURVEY OF PROPERTY
PREPARED FOR
ELEANOR G L A/!/GHAM
BE/NG
LOTS 927- 934 INCL.
MAP OF SPUTNq M LAKE'
si rvArE /lv
TOWN OF PATTERSO/V
PUTNA M COUNTY NEW YORl
SCALE 1"20' .
Sold mop filed Morch 2o, /93l os Moo N° /45
C. E0,9ett, the surveyor who mode
do hereby certify "hot the survey
rope ?rty shown hereon wos completed
/96.9,
LIN
L /'sense Ne P12
?91st Potion NQ5632
se of ✓omes C. Edger"
L or. )d Surveyors
Cry ao� Rrnwe!o� /1/aw Ynrl•
nereon.
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Sheet of
PUTNAM COUNTY DEPARTMENT OF HEALTH
S"ION�OF'ENVIRONM T'LH SERVIGE18 - = -::__
FIELD ACTIVITY REPORT
Street Town State Zip
PERSON IN CHARGE
OR TNTRRVTFVJF.T)-.
Name and Title
TYPE OF FACILITY :lJ SYs 2</-�=-c
FINDINGS:
1 acknowledge receipt of this report: SIGNATURE:
02/96 Title;_
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I SURVEY OF PROPERTY p )E �\pi PREP.4RE0 FOR 0ELEANOR G L ANGHAM. 5 SONG J� 5� S L OTS 927 - 934 /NCL . �• O llq , \ ��
SHOWN ON 40 AO '
'%LL4P OF PUTNA'N! LAKE rJ� �Z4
S/TUATE /N d° i r I�
TOWN OF PATTERSO/V
PUTNAM .COU/VTY, NE•W YORK ,50 Z
SCALE /
=20' BA% �Z
°{ Said MOP filed March 20, /93/ os Mop NQ149
\-zp-'
8 �4
re ec�6 block \ (G nd f'On
dirt porkln90 L/ \ y \\ I M
536 O E /60.62
/, James C. Edge /t, the surveyor who mode � � r
/his mop, do hereby certify Mot the survey
L the properly shown hereon wos comp /eted RHINE /FF f50'wida / `. ROAD
- June 6, /969.
Note: A// c6rtificohbns hefebn ore clfd for this Legend
ye C' 6 ' mop ono' copies thereof only Vmid .mop
New YorR License Nf 2r2 or copies boor the impressed sso/ofrhe.. poles w
Conn. Registration Np5632 surveyor wGnse sionoi uie appears hereon:' stone wall
Office of ✓omas C. Edgert pipe found —
to nd Surveyors - iron Pin set - -o ✓09 N- °E9095
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