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BOX 24
02870
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02870
OWNER'S NAME S
PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
PROPOSAL FOR SEWAGE DISPOSAL SYSTEM REPAIR
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SITE LOCATION a �� % g' /'c/ e. TK#
MAILING ADDRESSco f
PERSON INTERVIEWED Pam Caq3laint #
_ Name & Relationship (i.e, owner tenant, etc.)
DATE :f 4:_ TYPE FACILITY
PHONE
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.
1 Disapproved
inspec;wr • 5
/Ilato
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 canponents tied to two fixed points (e.g.,house corners).
d. System description (e.g., 1250 gal. concrete septic tank, three precast 6' diem. 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 rted agent owner a ree to the above conditions.
SIGNATURE TITLE DATE
Tz'gS: White (PCHM; YeUm (Tam HE); Pink (AFpl amt)
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A14E-S ✓. E DELLA UAFFEE MARTHA F. KRASSNER
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' Q5 e I SURVEY OF PROPERTY
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SITUATE IN THE
TOWN OF PUTNAM VALLEY
PUTNAM COUNTY
NEW YORK
SCALE / "• /0' OATE: SEPT. /,/976