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BOX 31
03995
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03995
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OWNER'S NAM
SITE LOCATION �
MAILING ADDRESS
PERSON INTERVIEWED
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PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMEN'T'AL HEALTH SERVICES
225- 3838/225- 3833/225 -3641
PROPOSAL FOR SEWAGE DISPOSAL - SYSTEM REPAIR
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Name & Relation:
PHONE
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PCHD.Complaint #
.e, owner, tenant, etc . )
TYPE FACILITY
I PHONEi�i'�
Proposal (include sketch locating all adjacent wells):
NOTE: Repair must be in sa1W 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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Proposal approved Proposal Disappeoved
Puna COLMY
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Inspector's Signature & Title D4fe
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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 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 owner, 9x1re po of pt agree to the above conditions.
�S�GNA TITLE: G/ - DATE
PIES: WAte (TCHD); Yel1cw (Tcwn BI); Pink (Appl.ioant)
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Lake Drive
LAkeland 8-6842
Lake Peekskill, N. Y.
.----j�leaning Specialist of
EASTERN STATES SEPTIC CO,
TRENCHING.
DIGESTERS.
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ANY TOWN OR STATE
DRAINAGE BEDS
IMHOFF TANKS
SEPTIC TANKS
SEPTIC TANKS
CATCH BASINS
K. R. LIETZ & SONS
CESS POOLS INSTALLED
BOOSTER PITS
Raymond K. Lietz & Kenneth J. Lietz
CITY DIS. PLANTS
OIL PITS
OIL STORAGE TANKS
Owner & Operator
INDUSTRIAL SLUDGES
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6 Lake Drive
LAkeland 8 -6842 Lake Peekskill, N. Y.
: Cleaning Speyialist TRENCHING
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DIGESTERS DRAINAGE BEDS
IMHOFF TANKS ANY TOWN OR STATE
SEPTIC TANKS
SEPTIC TANKS
CATCH BASINS K. R. LIETZ & SONS CESS POOLS INSTALLED
BOOSTER PITS Raymond K. Lietz & Kenneth J. Lietz CITY DIS. PLANTS
OIL PITS Owner £, Operator
OIL STORAGE TANKS
INDUSTRIAL SLUDGES
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.LAkeland 8 -6842
Cleaning Specialist of
DIGESTERS
IMHOFF TANKS
SEPTIC TANKS
CATCH BASINS
BOOSTER PITS
OIL PITS
OIL STORAGE TANKS
INDUSTRIAL SLUDGES
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EASTERN STATES SEPTIC CO.
ANY TOWN OR STATE
K. R: LIETZ & SONS
Raymond K. Lietz & Kenneth J. Lietz
Owner & Operator
Lake Drive
Lake Peekskill, N. Y.
TRENCHING
DRAINAGE BEDS
SEPTIC TANKS
CESS POOLS INSTALLED
CITY DIS. PLANTS
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