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02437
PUTNAM COUNTY HEALTH DEPARTMENT
�t�PM CpG� DIVISION OF ENVIRONMENTAL HEALTH SERVICES
* pROPOSAL FOR SEWAGE
0 ICIAL USE ONLY
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SITE LOCATION -1 r16
OWNER'S NAME,4r n t
MAILING ADDRESS
PERSON INTE
DATE 'I 1
PROPOSED INSTALLER
ADDRESS a 11 `S b. S
TM# _'S^6o 2G - / 17 3 8 3,3 t/li
RVIEWED A O e Pews w n &r- PCHD Complaint #
/ Name a atlons Ip i.e., owner, tenant, etc.
TYPE FACILITY
2., Plum binc
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1� REGISTRATION# PC
Proposal (include sketch locating all adjacent wells):
17,-
,to
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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I, as owner, -or reported agent _of owner agree to the conditions stated on this form.
SIGNATURE TITLE d n ✓ DATE `16
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 ormed in accordance with the above proposal and conditions.
Proposal approved I
Spector's Signature & Title DATE
COPIES: White (PCHD); Yellow (Town BI); Pink (applicant)
PC -RP 99NE
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FROM j � DAKA PLUMBING ANIi HEATING CO
FAX N0. .: 845 223 9128 Mar. 03 2006 04:03PM P2
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MAR -3 -2006 FR1 I. •: 31 TFI : R4c;— ?7R -7gPl KIOMG• GI ITKIOM f -ni IA
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FROM i DAKA PLUMB I HC, AND HEATING CO
SITE LOCATION
OWNER'S NAME '
MAILING ADDRI
PERSON EqMRVI
DATE.
PROPOSED INSU
ADDRESS .2115
FAX NO. : 645 223 8128 Mar. 03 2006 04:03PM P3
-HEA ', -H
-PuTNAM COUNTY EX `DEPARTMENT
-
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
jm#
_PCHD Complaint #
TYPE FACILITY
PHONE
Proposal (include sketch loiating afl.adjaceat 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 e4ueeroir registered architect.
as owner, or reported agent of.owner agree to the conditions awed on this farm..
SIGNATURE T= n D . Mi. 7 % ��a�
Loi e
.-I!ropQsW aq=ynad 3jC& ihr,&1jQwjngmi1djtjQz-
1. Procurement of any Town p=ft, if applicable.,
.2. Sub fission of as built repair sketch in.duplicae-showing:
a. Owner's name
b, Site Street Name, Town and Tax Map number.
P. Location of installed cOmponents tied to two fixed points (e.g.,house comers).
d. SYS1em description (e-9;,Jj50 gal. Concrftseptic.tank, three precast 0diam". X 6' deep
e. Installers' name and number.
3. Systcrn repair to ormed in accordance with the above proposal a'nd'conditions,
Proposal approved
let
ctor's Signature 8t Tffilr�`
,Ac DATE
1 1
COPIES: Wbite, (PCHD); Wo w own
BI); Pink (applicant) ant)
own
99NI
4.
MAR-3-2006 FRI 15'32 TEL*845-279-7921 NAME-PUTNAM COUNTY DEPARTMENT OF P. 3
FROM •: DAKA PLUMB [ Fdl= AND HEATING CO FAX NO. : EW5 223 8128
D A K A PLUMBING & HEATING
2115 RTE 55
LAGR.ANGEVILL.1~, NY 12540
845 -724 -5615
$45- 223 -$128- FAX
Mar. 03 2006 04:02PM P1
Send toc g F'a' ®nn:
Attention: m lch 3Ud Z1 n34' Date: eD 0 f, 0
Office location: Office location:
Fax number g14�_ 2 -7g _.75C�/
Total pages, including cover.
Phone number:
44S- 724-.8 t S-
I
J
MAR -3 -2006 FRI x.15:3:1 TEL:845- 278 -7921
NAME:PUTNAM COUNTY DEPARTMENT OF P. 1