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36.49 -1 -22
BOX 18
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SITE
PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
OFFICIAL USE ONLY
X11
LOCATION 'V1
PERSON INTERVIEWED PCHD Complaint #
—Aacwe Kc a ati ns ip i.e., owner, tenant, etc.
TYPE FACILITY /Y QJ ,
DATE y —
PROPOSED INSTALLER S - PHONE
ADDRESS
� REGISTRATION#
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. A
I, as -owner; ,or reported agent of owner agree to the conditions. stated on this form.
/ - (�
SIGNATURE TITLE I/ P DATE
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 (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 p ormed in accordance with the above proposal and conditions.
Proposalapproved
a
Inspector's Signature & Title ATE
COPIES: White (PCHD); Yellow (Town BI); Pink (applicant)
PC -RP 99ML
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SHERLITA AMLER, MD, MS, FAAP
-. _Commissioner. of
LORETTA MOLINARI, RN, MSN
Associate Commissioner of Health
Stuart W. Bates Inc.
114 Starr Ridge Road
Brewster, NY 10509
Dear Mr. Bates:
DEPARTMENT OF HEALTH
1 Geneva Road, Brewster, New York 10509
ROBERT J. BONDI
Executive_ ,
September 20, 2005
Re: Repair — Incomplete
41 Ingleside Road
(T) Patterson, TM # 36.49 -1 -22
Review of plans and other supporting documents submitted at this time relative to the above -
regarded repair has been completed. The following was not submitted with your application:
1. The septic repair sketch submitted to this Department does not show the existing and
proposed septic system.
2. Measurements from the existing and proposed septic to surrounding wells have not been
shown.
- ----= upo nTeceiprofa-submission ;•revi -sedto- reflect- the -above- commeiits ;- this-repair-application -will- - - be considered further.
GR:kly
1
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Sincerely,
:44_kc- V-)
Gene D. Reed
Senior 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
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