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41.10 -2 -21
BOX 20
02312
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02312
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PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
M ' P1tOPOS i:'PDR °SEVi%AaEDDISP®SA ;,SYSTE'MREPA�R'
OFFICIAL USE ONLY
SITE LOCATION 526 Lake Shore Dr. E. Put Vly TM# 41.10-2-18,19,20,21
OWNER'S NAME Vincent o' Hanlon PHONE 845- 526 -4293
MAILING, ADDRESS same
PERSON INTERVIEWED V. o 'Han 1 o n (owner) PCHD Complaint #
ame & Relationship i.e., owner, tenant, etc.
DATE November 7, 2003 TYPEFACILITY Private Dwelling
PROPOSED INSTALLER J Mantovi Excavating, Inc. PHONE 845- 628 -4526
ADDRESS 485 Kennicut Hill Rd, Mahopac, NY REGISTRATION# 13 -01
Proposal (include sketch locating all adjacent wells):
NOTE: Repair must be in same location and of ame type as original sewage disposal system .Different location
may require submittal of proposal from license4professional engineer or registered architect.
)lace existing steel septic
nk with a new 1,000 gallon plastic tank.
lr
4S- owner - r. reported agent of owner agree to the cond' 'ons stated. on this form.
SIGNA o �I` - Lr�-t TITLE j ✓ DATE 11 7r e,,
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 performed in accordance with the above proposal and conditions.
r
Proposal approved /---
Inspector's Signature & Title
COPIES: White (PCHD); Yellow (Town BI); Pink (applicant)
PC -RP 99ML
DATE
;J 11/10/2003 .12:42 6287265 JOE MANTOVI V__� I PAGE 01
PUTNAM COUNTY HMTH DEPARTMENT' -
OFF&"M USE OWL
yc� 03
SITE LOCATION 526 Lake Shore Dr. E. Put vly TM# 41.10 -2-18,19,20,2
OWNER'S NAME -Vincent 0' Hanlon pHONE 845-526-4!93
MAELING ADDRESS same
PERSON YNTERVIEVVED V. 0 'Han 1 o n ( owner) pCHD Complaint #
aape I.&, owner, [,
DATE Nove ber 7, 2003 TYPEFACUM Privat Dwelling
PROPOSED INSTALLER a 14antovi Excavating, Inc. PHONE 845- 628 -452
ADDRESS 485 Kennicut _l i,ll Rd, Mahooac, NY REGISTRATION# 13 -01
per, W (include sketch locating all adjacent wells):
NOTE: Repair must be in same location and of a type as original sewage disposal system .Dill t location
may require submittal of proposal from license# professional engineer or registered architect.
tins steel
th
a " ._ r repeated` ent. of owner _agreC.t i:t11C Cbdi '�itl $tatL�d -o thl[s r�l: . ` .
SIGWA DATE
tank.
Emul ap=IW yft the fo (Q_mdng Bondi
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 Udk, three precast 6 diam. X deep
e. Installers' name and number.
3. System repair N be performed in accordance with the above proposal and conditions.
Proposal
Inspector's Signature & Title
COPIES: White (PCHD); Yellow (Town B4 Pink (applicsatt)
PC -RP "UL
DA
NOU -10 -2003 MON 12:41 TEL:845- 278 -7921 NAME:PUTNAM COUNTY DEPARTMENT OF P. 1
Pe ��
PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF. ENVIRONMENTAL ENTAL HEALTH SERVICES
-IAj� , -
rimurniaAJU r %imar, VV mar, Allary, -JX0AX!,1V11inra
OMCIAL-USE.010LY -
•
CD
�3 9
SITE LOCATION' 526 Lake Shore Dr. 14"'. -1,-,u t- V1
TM#
OWNER'S NA L Vincent 11Han_1c,,,
PHONE 3- 5,;
MAILING . ADDRESS
C4
PERSON INTEiMEWED V., 0`H.an1cn (Owrler) PCfID Complaint
(Lei� owner, tenant; tj etc.) 7:
DATE Fjovember 7, 2003 TYPE FACILITY P 'J
PROPOSED INSTALLER J. Mantovi Excavat -ing , 1,,c. —PHONE
ADDRESS 485 Kennicut: Hill Rd, Bahopac, 9Z REGISTRATION4
Proposal (include sketcli'l6catihg''all adjacent wells):
NOTE:- Repair must beisame'loc ation and ,ofsame type as original sewage disposal system Diflerent location
may require submittal"-' of proposal from lke4se4:professional .engifio er. or registered architect
'-,
Re _dCe'-:.exist1ncj�J1t' Selp Ic;; t El I rl I 1 :% W I th
a t ion
1, as.pymer;,Qr.reported agent of owner agree tc
SIGNATU�t —,-,0.4
V
the conditions stated on.-this.-form.
TITLE .)iDAI'E 7' r-
Proposal approved with the following conditions:
1. Procurement of any Town permit, if �applicable.
2:' Subiiiission'of as uiii.repaiT'rsketchmduplidatdshb,,,,ing.-
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 prec-3'st 6' diam. X Gdeep
e..,, Installers' name and number.
3. System repair to be performed in accordance with the above proposal and conditions.
. ............
or. s i S' gnature&TitIe.`--.- i.
DATE
COPIES: White (PCHD); Yellow (Town BI); Pink (applicant)
PC-RP 99NE
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