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PERSON INTERVIEWED PCHD Camplaint
Name & Relationship (i.e, owner,tenant, etc.)
DATE TYPE FACILITY
PHONE `2- ? :2 —kj-0 :2
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 fran licensed professional engineer or
registered architect.
Proposal a ed Proposal Disapproved
Inspector's Siqna ure & 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 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, or reported ag of owner agree to the above conditions.
SIGNAZURE' C , TITLE_. DATE / (1
TM: Hlite (PQ D): (pn EU; Pink (Appl.io3nt)
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14
PETER C. ALEXANDERSON
County Executive
DEPARTMENT OF HEALTH
Division Of Environmental Health Services
110 Old Route Six Center, Carmel, New York 10512
(914) 225 -0310
Roger Clap
'Fair Street
Carmel, New York 10512
Dear Mr. Clap:
January 29, 1991
JOHN KARELL Jr., PE., M.S.
Public Health Director
Re: Septic Repair -As Built Sketch
An application for a sewage disposal system was approved by the Putnam
County Health Department on July 2, 1990 The approval was granted
with the following condition.
'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 poin):s
e corner.. -
d) System description (e.g., 1250 gal. concrete tank, three
precast 6' diam. x 6' deep drywells surrounded by one foot
+ gravel).
e) Installer's name and number.
You are responsible for submitting this information to the Putnam County
Health Department within 30 days. Failure to do so will make you liable
for penalties provided by law.
If you have any questions please feel free to contact me.
For the Public Health Director
t/iry my yo s
Johfi Karell Jr., P.E.
Public Health Director
By:
MB:CJ:jr Chris Jo son
Intermed to Clerk
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