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PERSON INTERVIEWED PCHD Complaint #
Name & Relationship (i.e, owner,tenant, etc.)'
DATE a-� [ 3l 7 a TYPE FACILITY t 'D
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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 fran licensed professional engineer or
registered architect.
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Proposal approved
Inspector'. s Sig e &
Proposal Disapproved
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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 ccmponents 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 to be performed in accordance with the above proposal and conditions.
I, as owner, or reported agent of owner agree to the above conditions.
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SIGNATURE TITLE & J k C (t- DATE ?i
CPIES: WAte QED); YeU c w (fin BU; Pink (Appliamt)
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PETER C. ALEXANDERSON
County Executive
Gary Adler
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DEPARTMENT OF HEALTH.
Division Of .Environmental - Health Services
110 Old Route Six Center, Carmel, New York 10512
(914) 225 -0310
46 Unidilla Road
Putnam Valley, New York 10579
July 31, 1990
JOHN KARELL Jr., P.E, M.S.
Public Health Director
Re: Septic Repair -As Built Sketch
Unidilla Rd., PV
Dear Mr. Adler:
An application for a sewage disposal system was approved by the Putnam
County Health Department on February 27, 1990 The approval was granted
with the following condition.
Submission of As -Built repair sketch in duplicate showing:
a) Owner's name.
b) Site Street Name, Town and Tax Map number.
L;r i•u3 t —j 1.x'1 C- .r Cn`eily 8- t 1 t r
(e.g., house corners).
d) System description (e.-g., 1250 gal. concrete tank, three
precast 6' diam. x 6' deep drywells surrounded by one foot
+ gravel).
e) Installer's name and number.
You are responsible for submitting this information to the Putnam County
Health Department within 30 days. Failure to do so will make you liable
for penalties provided by law.
If you have any questions please feel free to contact me.
For the Public Health Director
ery my rs
-'°�ohn -Car e11� Jr., P.E.
Public Health Director
By: ol'i'",
MB:CJ:jr Chris Johnson
Intermediate Clerk
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