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4� PUTNAm ax wry HEALTHY DEPARnma - 3 1 * DIVISION OF ENVIRONME[�TPALIHEALTH SERVICES
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04� PROPOSAL FOR S3&GE DISPOSAL SYSTEM REPAIR
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1
OvMIS NAME ln.1� yeonge gjentnen
SITE LOCATION 54 SeL. ent -Lane Putnam VaUeu, NY 110579
MAILING ADDRESS 54 SeL.i -nt Lane Putnam VaUeu, NY 10579
PERSON INTERVIEWED Geox Gentnen (Owneni
PHONE 528 -2893
PCHD Complaint #
Name & Relationship (i.e, owner,tenant, etc.)
DATE Septemben 21, 1995 TYPE FACILITY
PROPOSED INSTAL liahonac SanLfatLon Se.,2ti.c, Inc.
REGISTRATION # 41 2/7 Kenni.cut flill (oad - lkhopac, AT
Proposal (include sketch; locating all adjacent wells);:
NOTE: Repair must be in same location and of same type as original
Different location may require submittal of proposallfran licensed
registered architect.
Odd 5 41' x 41' ga,l.0 Lei to ex i.4- in, P U .
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Proposal appro�t1 --�z� Proposal Disapproved
Inspector's Signature & Title
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.
innLvate Dwd ink:
PHONE 626 -4526
sewage disposal system.
professional engineer or
�-� 7A�-
Date
b. Site Street Name, Town and Tax Map number.
c. Location of installed camponents 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. SystU-- .repair to be performed in accordance withlthe above proposal and conditions.
I, as own or reported ag t of er, agree to the above conditions.
SIGNATUR U%l�. TITLE �-� DATE � c1 S. ze)�
IPD:5: Mite (PCHD); YeUcw Mkn ED; Pink (AppUamt)
MAH ®PAC
SANITATION SEPTIC, INC. {
Septic Tank Service
Kennicut Hill Road
MAHOPAC, NEW YORK 10541
628 -4526 Joseph A. Niantovl
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