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73.05 -1 -55
BOX 27
03317
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03317
PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
PROPOSAL FOR SEWAGE DISPOSAL SYSTEM
\ OFFICIAL USE ONLY
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R 73-OI
SITE LOCATION �7 1 i/L4 0 Tc7�4�1�f y �.i� le TM# ` _
OWNER'S NAME Z-y W C. J--1 v cC ODI1.2, O A N PHON CZ b 3
MAILING ADDRESS
PERSON INTERVIEWED PCHD Complaint #
ame & Relationship i.e., owner, tenant, etc.
DATE TYPE FACILITY
PROPOSED STALLER w . �iLf1 h� PHONE JP:S .--� -'ZS-Fr
ADDRESS p a - -N +7 J 937?9 REGISTRATION# `� L
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 o_f brc osal from licensed professional engineer or registered architect.
T, as eI.w Ier; Gr rep_orted agent of owner 4gr; e j `hi cqnditions st#tpd-
SIGNATURE TITLE Y ? t/ DATE Z
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 corners).
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 performed in accordance with the above proposal and conditions.
Proposal approve
Inspector's Signature & Title DATA
COPIES: White (PCHD); Yellow (Town BI); Pink. (applicant)
PC -RP 99ML
t - .
SITE
MAIL
PER$ULV 11V'1ritCV1rltlW x�asi wli�sasaa►. �
& Relationship (i.e, owner,tenant, etc.)
DATE TYPE FACILITY
PROPOSED INSTALLER C raw � ��� � n�� � PHA
Pro (include sketch locating all adjacent wells): k%!X-,(-&P
N=.- 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 engines or
registered architect.
w4s Signature & Titlo
)roved with the follac
Proposal Disapproved
conditions:
PNL
Datfe
1. Procurement of any Town permit, if applicable.
20 Submission of as built repair sketch in duplicate showing:
a. owner's name.
b. Site Street Name, Town and Tax leap number.
c. Location of installed c mponents tied to two fixed points (eog.,house corners).
d. System description (e.g., 1250 gal. concrete septic tank, three precast 61 diama x 61 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, o e agent of owner agree to the above conditions.
SIGN TITLE DATE
LL&Itb: ftte 0 D); YeUcw M94n ED.- Pink (Appl amt)
SANTORE & API EXCAVATION, INC.
Box 69A Mountain View Rd., Putnam Valley, NY 10579
DATE
914 - 528317,
Quantity
Description
Amount
� � s
/
' J
IKO
TOTAL
Not to bs held n�ponslble for blasting A�
underground lines: cabk, water, slsdrlal, DEPOSIT
etc. unless spw"wd
BALANCE
LOT /V-e -34&
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SURVEYED & PREPARED BY
BUNNEY ASSOCIATES
ENGINEERS & SURVEYORS SCALE
156 KATONAH AVE.
KATONAH, NEW YORK
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row 04F
SURVEYED & PREPARED BY
BUNNEY ASSOCIATES
ENGINEERS & SURVEYORS SCALE
156 KATONAH AVE.
KATONAH, NEW YORK
VA d E I.
1=)1-17-1V,41W COUIV77)'
X.
V I—r W eOR A:: N
N, o. 7-- 708 -.-i