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OWNER'S NAME
SITE LOCATION
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PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
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Name & Relationship (i.e, owner,tenant, etc.)
DATE TYPE FACILITY
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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.
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's Signature &
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 ccanponents 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 be performed in accordance with the above proposal and conditions.
as owner, Me t o the-above conditions.
IGNATURE TITLE 7� a DATE
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CERTIFIED RETURN RECEIPT REQUESTED
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DEPARTMENT OF HEALTH
Of Environmental Health Services
Road, Brewster, New York 10509
(914) 278 -6130
PLEASE REFER CORRESPONDENCE TO:
NAME: Mel Kek
TITLE:: Engineering Aide
PHONE: (914) 278 -6130 Ext. 16
BRUCE R. FOLEY, R.S.
Acting Public Health Director
OFFICIAL NOTICE OF NON OOMPLIANCE
YOU ARE HEREBY NOTIFIED that non - compliance with Article III Section 4 of the Putnam County
Sanitary Code consisting of a discharged of sewage onto the surface of the ground was found at
your fWa7_y OF AeAWO(V 9�, PATJF- IVy, by a representative of this Department on
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believed that you are responsible for correction of this condition. If you are not
sible, you are requested to notify immediately the inspector above indicated.
Please be advised that appropriate steps must be taken immediately in order that the sewage
overflow cease by arranging for the septic tank to be pumped out and maintained pumped until
proper repairs are made to the system.
Approval of proposed repairs must be obtained from this Department prior to any alteration or
rebuilding of existing disposal systems. An application is enclosed.
lure to maintain the septic tank pumped and further, to correct,this condition by
1995 will make you liable for additional penalties provided by law,
uding prosecution on a charge of committing a violation punishable by a fine or imprisonment,
both such fine and imprisonment, as prescribed by law, in addition to such other action as may
prescribed. A reinspection will be made.
sincerely hoped that the above mentioned further action will
cooperate by securing the correction of this condition.
For The Public Health Director
truly yours,
Bruce R. Foley, R. S.
Acting Public Health Director
BF /MK /jp By: Mel Kek
Enc. Permit Application Engineering Aide
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noncompliance
be necessary and that
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