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PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
PROPOSAL FOR SEPOM DISPOSAL SYSTEM REPAIR.
OWNER'S NAME Robert and Joan Kerr PHONE 526-2'444
SITE LOCATION 24 William Street TO
MAILING ADDRESS 24 William Stree't, Lake Peekskill, NY
PERSON INTERVIEWED PCHD Cayplaint. #
Name & Relationship (i.e, ownerltenant, etc.)
DATE . TYPE FACILITY
PROPOSED INSTALLER Stephen Kastuk, Inc. PHONE '528-2290
Proposal (include sketch locating all adjacent wells):
Nam: 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.
A 70'
Proposal approved
Inspector I s _tm
Proposal Disapproved
Proposal amroved with the followina 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.
Date
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 61 diem. 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.
as owner, or reported age I
of owner agree to the above ditions.
SIGNATURE TITLE DATE t��
FW: White (PAD); YeUcw (mn H1); Pink (Aftilmnt)
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STEPHEN KASTUK, INC.
36 Lindsay Lane
Putnam Valley, New York 10579
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