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PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIROIODWAL HEALTH SERVICES
225 - 3838/225 - 3833/225 -3641
: PROMM AL• FO1.3E =•AGE - DISPOSAL SYSM4 - REPAIR
OWNER'S NAME �le , fit S, G �� SS /VI 1� PHONE
SITE LOCATION T M#
MAILING ADDREE
PERSON INTERVI
DATE
PROPOSED INSTMJM PHONE O'll?el!!�7
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 architect.
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Proposal approved - t- Proposal Disapproved
Inspector's Signatur Titl Date
_Proposal approved with the following conditions:
1. Procurement of any Town permit, if applicable.
2. Suhni.ssion 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 canponents 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, or rted gent of owner agree to the above conditions.
SIGNATURE fb 01UtikrR TITLE DATE
FW: 4bite MD); YeUcw (cn HE); Pink OgJli,cant)
ALL-PAO
inc.
-Sewer &-Drain, Sdrvice-
Elmer Galloway Rd. Katonah, NY 10536
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914-225-2746
914-232-8888
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