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BOX 25
03102
PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
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PROPOSAL FOR SEWAGE DISPOSAL SYSTEM REPAIR
OFFICIAL USE ONLY
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SITE LOCATION % � MW NlC,,9 `✓ i TM#
OWNER'S NAME 6914,k 6- doANa 'TPyhV NO PHONE
MAILING ADDRESS 'p, —t—t4P iz v V4 L La v" M IL / o
PERSON INTERVIEWED PCHD Complaint #
---Name & Relationship i.e., owner, tenant, etc.
DATE '�C%�Q TYPE FACILITY
PROPOSED INSTALLER ecyy PHONE
m s CA-
ADDRES S 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.
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SIGNATURE TITLE �' �~ DA._-:
Proposal annroved 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 G deep
e. Installers' name and number.
3. System repair to be performed in accordance with the above proposal and conditions.
Propos a roved
Inspector's Signature & Title DATE
COPIES: White (PCHD); Yellow (Town BI); Pink (applicant)
PC -RP 99NE
PUTNAM COUNTY HEALTH DEPARTMENT VIZ
DIVISION Of ENVIRONMENTAL HEALTH SERVICES
.7 77
PROPOSAL FOR SEWAGE DISPOSAL
OFFICLAL USE ONLY
AID
4_ (
,
SITE LOCATION 'S AH W t- "71
OWNER'S NAME egiriv, *Q0wNvt PHONE 8''S" :4,(
MAILINGADDRESS
0.
DATE ail
TYPE FACILITY � -
._1 4 �_.a S.
4ROPOSED INSTALLER �AaA.,V,+q) rof�e,�& 4 4,'r, PHONE 1-
ADDRESS REGISTRATION#
:4
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.
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k
I f: L j) 1
C LLJC� 1-o
-as-G1VVr1ei_.1 (A-repuf lid�k� of-owilef aj�eeF to eohcHtifts stated Oiftifis lorm.
N
SIGNATURE� .. %
DATE
Pro.posal approved with the following conditions:
rocure
'P ment bfao' nit, ,if applicable
pphcable,,
M'dupi
2. Submission of as built repair sketch 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 tank, threep'recast 6'diam. X Gdeep
e. Installers' name and number.
3. System repair, to be performed in accordance with the above proposal and conditions.
..iPropos 4pproved 11.,
Inspector's Signature &Title..
COPIES: White (PCHD); Yellow (Town BI); Pink (applicant)
PC-RP 99MI
16X-TE
N."
HOWARD GRAGERT f-C 13
296 OSiCAWANIA LAKE RD
Z3 PUTNAM VALLEY NY 10579-2000
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Area 999 Sq. Ft.
�i l `f S � Z -) �r�OD
77- Nw is crfitmd only to:
JOHN rUROCI
1.1,*M C MROCI
51eLfY CORPORAT ION
COMMONWEALTH LAND rlrLE INSURANCE CO
for inot, rille fiff 0644944P
BADEY 8 WATSON
Skrmyov a Engineering, PC.
U. S. Roof 9
Cold Sa"m , NY 10516
(9141 265 -9217
Nolen
I. /+livvttoft of Ms docam'mit, except by a licensed Land
51,;-yar, is illegal. I
2. All certificallons are &�Ild fm this =0 and copies
ti,dreaf only if said ONX.: or tooter AM, the e.Awed
", of the surveyor -Ar.w "goat.- amocom hereon.
5 141cfwgravad ImprovemerfT , easements ar encrocclallots,
If 7 , are rat shorn imfew.
4. r,f41
Promises shown Avon is /Of NJ? 97 as Stoffn
a7 'hot certain moo er I.-Wod 'M..;if1vd Map NO 2
of Abelo Part ... p " m. ch was filed /A the Putire,
C.71fify Clenti Office ,,. August 25, 1926 as
l"Ife, Map NO ea.
k
.It 01,,X.
t
J11
SURVEY OF PRqP��rY
MIFIRAREP IW- _`%Zt"�_
JOHN e LIMA F-��,,T-ZIROCI
SITUAM IN THE
N OF PUMAP C011N7
NEW YORK
SCALE /in. =20 ft JUNE lgff�
We A"ty cwWfy tjW the sm-d3, shorn hereon
Nm 00-pieted by as on Jame /1 1988 1 Mot
'his Map vas camp /~ m 15 , 1.988,
mw Ither this survey t,=. wepo"d in accordance
wih fne existing Code of pkactive for Low Skrms
as aeopree by The Ar. Yc,* smarr Association of
Professional Land Stavoyps, Inc.
'
A
OADEY a WAMON
SURVEYING a rNSINEOMS'P.C. 4
45066 by 02
No IVIF. MRW 611A
L �A
C7)r0 LAND. SURVEYOR
"C"VSr
SIF No 458651