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PUTNAM COUNTY HEALTH DEPAR24RU
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I� 225- 3838/225- 3833/225 -3641
V
PROPOSAL FOR SEWAGE DISPOSAL SYSTEM REPAIR
OWNER'S NAME
SITE LOCATION
MAILING ADDRESS
PERSON INTERVIEWED c. ' PCHD Complaint #
Namd & Relation p (i.e, owner tenant, etc.)
DATE TYPE FACILITY
PROPOSED INSTALLER PHONE
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 archite�t ��
with the following conditions:
1.'Procurement of any Town permit, it 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.
as own or reported agent of owner agree to the above conditions..
[GNATURE CC r_a TITLEr''i DATE L2- 4-1 _+
ES: %Ate (PCE D); Yellow (Tom HI); Pink (A�plicant)
PUTNAM COUNTY HEALTH DEPARTMENT
blvigl& OF'FNVIRONMENTAL HEALTH SERVICES
John M. Simmons, M.D.
Deputy Commissioner of Health - FIELD ACTIVITY REPORT - Sheet of
,INSPECTION
NAME
Orig. Routine
ADDRESS a 'e'l" //( �e
No. Street Tawn TM No.
MAILING ADDRESS '
. P.O. Box Post Office Zip Code
TELEPHONE
PERSON IN CHARGE
OR INTERVIEWED
Name and Title
DATE :�`" U TYPE FACILITY
TIME ARRIVEDj, �1 TIME LEFT
Orig. Canplain
Orig. Request
Canpl iance
Complaint Canp
Final
Group Illness
Construction
Reinspection
Field, Sampling Only
Field Conference
Other
Explain
FINDINGS:
P
INSPECTOR: �°�� TELEPHONE:
Signature and
PERSON IN CHARGE OR INTERVIEWED:
I acknowledge this Field Activity Report. SIGNATURE:
6/86 TITLE:
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CERTIFIEDt TO
MAP V" -it.Ed /N
'1 :j,.r..•I }tl 1.'"'1,11 {
7Ar OFF /CE QF T.VE C1_XJArrY r i ,zj/r IM
•o, ' "�i s ! y i `i I
GUUNTY cI"— /i/V 44AYZB. 1929 .ex 4&,o
SURVEY OF PROPERTY
FOR
JOSEPH WRAONO
SITUATE IN THE
%U.+/.✓ of- Pur.41W V&4- -Y
Alr lw COUNTY
NEW YORK
SCALE: 1"- 1.5•
SURVEYED AS IN POSSESSION
{
CERTIFIEDt TO
'1 :j,.r..•I }tl 1.'"'1,11 {
:i.
,.,y •
�Ai
Certifications hereon are valid for Bank,
�•
SURVEYED:• zw,1 -me
Title Co. 8 Own en for this transaction
+ t • " ' °.k'! i B
s DATE
Certification are not transferable to
.I�UGHTonly.
1 tTO
subsequent Bank, Title,Co, or Owners.
BROUGHT PTO DATE
All certifications thereon are valid for this
map and copies themes only if said
JOHN SAL:VATORE ROMEO
he s r-
copies bear }he:impreued Seel of the sur-
Consulting'Engincer &.land Survevor
veyor whose signature appears hereon.
t,r'NORTHRIDGE;i ROAD
"It is hereby certified that this survey was
"`'�BEEKSKILL IN �'Y,
;
prepared in accordance with •fho existing
A,,—A
Code of Practice for Lend Surveys adopted
by the New York State Association of Pro.
"P. E..181 L:; S.' "' NYS'LIC: NO. 027846
fessional Land Surveyors."
:NCROACHMENTS BELOW "ADE IF ANY NOT SHOWN
-
�:
SURVEY OF PROPERTY
FOR
JOSEPH WRAONO
SITUATE IN THE
%U.+/.✓ of- Pur.41W V&4- -Y
Alr lw COUNTY
NEW YORK
SCALE: 1"- 1.5•
SURVEYED AS IN POSSESSION