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BOX 18
02091
PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES _
PROPOSAL FOR SEWAGE DISPOSAL SYSTEM REPAIR /
OWNER'S NAME At. Risk Jahn
SITE LOCATION 7 Were% Road - Baewatea, NY
PHONE 763 -5199
TO
MAILING ADDRESS 7 OacAaad AiLve - SoutA Salem, NY 10590 - - - - - ......
PERSON INTERVIEWED R. ,9aAn (Ownea) PC HE
Name & Relationship (i.e, owner,tenant, etc.)
DATE AancA 4, 1996 TYPE FACILITY
cmviaint #
Rental dweULna
PROPOSED INSTALLER Wonac Santtaf, .on Sep ti..c. Inc. PHONE 628 -4526
REGISTRATION # 4_217 KennLcui 11U1 Rd. - IYIaAorac, NY.
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.
Rep.Cace ex Lat L%L Aept Lc tank Ln lame Locat Lon wUh
new iePtLc tank lame iLgee aA o,%Lq,u aL one.
S
Proposal approved. Proposal Disapproved
Inspector's Signature & Title 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 canponents tied to two fixed points (e.g.,house oorners).
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 own=reported agent of owneragree to the conditions. jJ SIGNATURE ��lX , ,,c T DATE IWO
lPlbi4: invite MD); Yellow (Txn BI); Pink (Aniiamt)
I
19AIVI
�7
.'MAHOPAC
SANITATION SEPTIC.—INC.,
Se,p"t"k, Tan
Kennicut Hill Road
MAHOPAC, NEW YORK 10541
628-4526 Joseph A. Mantovi
0
our
ONO
SITE
Proposal (include sketch locating all adjacent wells):
NOTE: Repair must be in same location and of same type as original swage disposal system.
Different location may require submittal of proposal from licensed professional engineer or
registered architect.
Proposal
s Sicjnature
2r,
&4
conditions-
Disapproved
mil!
s 10s t fa CR,
.L %d jai. cal+�ivvca,a ��,.ai ..av avaiv.a••.J
1. Procurement of apy 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 descriptign (e.g? 1250 gal. concrete septic tank,
drywells surrounded by one foot + gravel).
e. Installer's name and number.
L--� e
(e.g.,house corners).
three precast 6' diem. x 6' deep
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.
SIGMT(JRE ZA TITLE 'J'4 _ DATE //n /OP/
OPD I: write (P HD); YeUcw ffi); Pink (AppU=0
ALL AMERICAN ROOTER, �N(C.
103 SECOR ROAD MAHOPAC, NEW YORK 10541
-739,3388--%.628z 914 .. 238-A478-----;;;---
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azzi
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PHONE
STUART W..
BATES, INC.
Starr Ridge Road
BREWSTER,
NY 10509
(914) 279 -8952
CUSTOMER'S ORDER NO.
PHONE
DATE
/
NAME
1
ADDRESS
ASH
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CHi}1ROE:
ON /ICCT
MDSE RETD
PAID OUT
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TAX
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SOLD BY
RECEIVED BY
TOTAL
2 .j No