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PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH
PROPOSAL FOR SEWAGE DISPOSAL SYSTEM REPAIR
OWNER'S NAME An. Leonand Rohmen PHONE 528 -6915
SITE IACATION 66 Roc&Ue Road - Putnam Va�leu, l'Jy TM
MAILING ADDRESS 66 Rochda.Je Road - Putnam Va Ueo , NJ /0579
PERSON INTERVIEWED L. Rohmea (Ownen) PCHD Cwplaint #
Name & Relationship (i.e, owner,tenant, etc.)
DATE gune 24, 1995 TYPE FACILITY l n i.vat e dwd i as
PROPOSED INSTALLER Aaho ac SanLtaf-Lon Se ti.c Inc. PHONE 628 -4526 e
REGISTRATION # 4/ 217 KennLcut . 11al Rd. - Aahopac NY.
Pro (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 fram licensed professional engineer or
registered architect. / / 1) /
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Proposal a' Proposal Disapproved
Inspector's Signature & Title Da '
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
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 ownerf.,or reported.., a of owner agree to the above conditions.
SIGNATURE TITLE DATE
?lES: WAte (PAD); YeUc w Mkn HI); Pink (ApgUa nt)