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HomeMy WebLinkAbout4062DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 83.66 -2 -74 BOX 31 -01 mom ;-0 X. !'� 16 a F t �- � I ■ I L e t � ■1 �, i ` , 04062 ALLEN BEALS, M.D., J.D. Commissioner of Health R00FRYMORRT.S,.P:E=s 1 MY, f Director of Emironmental Health July 31, 2013 Alberto Lema 104 Spring Street, Peekskill, NY 10566 Dear Mr. Lema: DEPARTMENT OF HEALTH 1 Geneva Road; Brewster, New York 10509 Phone # (845) 808 -1390 Fax # (845) 278 -7921 Re: Addition — A- 086 -13 No Increase in Number of Bedrooms .70 Lake Drive (T) Putnam Valley, T.M. 83.66 -2 -74 1144MYELLEN ODELL County Executive This Department has received and reviewed the plans for the proposed addition to the above mentioned residence. The proposal for the. addition has been approved as per plans bearing the approval stamp from this Department dated July 31, 2013. The addition. is approved with the following conditions: 1.. The total number of bedrooms must remain at two without prior approval by this Department. -The ar=of the existing sewage disposal system and its expwsion area must be maintained. 3. All plumbing fixtures must be updated with water saving devices, i.e., new low-flush toilets, restrictors for shower heads. and faucets, etc ... 4. The approval is for the modifications only and does not validate any construction shown as existing that has not obtained proper approvals from other agencies having jurisdiction. S. This approval is valid fdr two (2) years and expires on July 31, 2015. Any permits or variances required under the jurisdiction of the Town of Putnam Valley are the responsibility of the applicant. If you have any questions, please contact me at (845) 808 -1390 ext. 43261. Respectfully, "� b t ��� Gene D. Reed Senior Engineering Aide GDR:cw cc: BI (T) Putnam Valley /,,.,riLLEN BEALS, M.D., 1D. Commissioner of Health ROB ERT P MORRI,, IF 'Director -oiEnvi'�r�o—n:.m"ent.-alHealth January 5, 2012 MARYELLEN ODELL County Executive DEPARTMENT OF HEALTH I Geneva Road, Brewster, New York 10509 Phone # (845) 808-1390 Fax # (845) 278-7921 Town Zoning Board 265 Oscawana Lake Road Putnam Valley, NY 10579 Re: Addition Procedures and Policies To whom it may concern: Please be advised that this Department recently revised its procedures and policies for the review of house additions. At this time the Department will not require a septic system to be updated to current codes due to proposed construction over 50% of the dwelling's original square footage. Acopy of the cu . rrent Procedures and Policies is enclosed. If you have any further questions, please contact me at (845) 808-1390 ext. 43261. Sincerely-,. Gene D. Reed Environmental Health Engineering Aide GDR:cw PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES PROCEDURES & POLICIES . FOR HOUSE ADDITIONS Bulletin HA-1 cw/proceduremanuaVEIA-1 May 2009 Revised November 2011 TABLE OF CONTENTS -R.® - IN'>If'R®IDUCTI' ON. -. ' .�_ .. .. .. : ..- ..s. .. ._ .. a f .. et._ .. 2.0 ADDITION GUIDELINES ...............,.,. ._.. ....._ . .e..�......r .r.a.f.... .e.d.e.a.e.a.e .s.a.0.a.a.a.a.a.c .x.... . -Fe.e 0 3.0 SIBIVI TTAL PROCEDURES .................. e..... e ........... e.ee . eeaeeeee . ee APPENDIX A. ADDITION APPLICAI'I ®N FORM ............. ............................... B. LEGAL BEDROOM COUNT FORM ........... ............................... C. SAWLE HOUSE PLAN SKETCH ............. ............................... fl 3 4 5 6 r/ r PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES L0 INTRODUCTION The Putnam County Department of Health (the "Depar(ment"), Division of Environmental Health services has developed this detailed guide for submission requirements, policies and procedures relative to approval of house additions. The Department must review and approve all proposed house additions prior to construction. The following is a description of the requirements of the Department for submission of an application for a house addition. The Department may require additional information or procedures as considered necessary, based upon engineering review of a project. Professional architectural house plans are not required for addition approvals by the PCDOH and it is strongly advised that . architectural house plans not be obtained prior to approval by the PCDOH. A pre - submission conference with the PCDOH staff is also strongly advised. 2.0 ADDITION GUIDELINES & PARAMETERS 1. The Department must review all proposed additions, which will result in an increase in living area 2. A complete tear down and rebuild of an existing residence will be reviewed on a case by case basis. 3. Adding any or a potential bedroom(s) to a house requires a Department construction permit for the expansion or complete replacement of the SSTS. The Department will determine the need for complete replacement of the SSTS based upon the age and condition of the existing septic system. 4. Houses destroyed by fire or other catastrophic event will be permitted to be rebuilt;,i kind; if they meet building departn_ent criteria for gr^ ,3fathor;tig:° 5. 4Houses which will not be rebuilt in the same footprint or do not meet building department criteria for grandfathering may require a permit for a new SSTS. If the subject lot is listed or determined to be vacant, than a new SSTS meeting current code requirements must be provided. 6. Any addition which is considered an increase in the potential bedroom count requires a formal approval of SSTS plans (Construction Permit) by the Department and plans are to be prepared by a Professional Engineer or Registered Architect in accordance with applicable sections of the Putnam County Sanitary Code, unless the SSTS is presently designed for the proposed number of bedrooms. The plans shall provide for the installation of additional and/or new SSTS area meeting present code requirements. (See PCHD Bulletin ST -19). 7. A proposed house addition shall not reduce the size of the existing SSTS reserve area. An addition which encroaches upon the existing SSTS or reduces the SSTS expansion area will require a formal Department approval (see # 6 above). 8. The Department does not object to reducing the number of bedrooms in a house since SSTS sizing is determined by the number of bedrooms. The addition of rooms such as dens, offices, libraries, exercise rooms, studies, bonus/unfinished rooms, etc. may be considered as potential bedrooms, and each will be reviewed on a case by case basis by the Department. 1. f- The determination of whether a proposed room addition to a -house is considered a potential bedroom will be made by Department staff based upon: - location of the room in the house _- S „_` -- .dam rvotn a. Accessory rooms such as dens, libraries, studies, computer rooms, offices, sewing rooms, etc. may be considered potential bedrooms. b. Large bedrooms, greater than 24 feet by 10 feet, which may easily be divided by a partition wall, may be considered two potential bedrooms. c. Storage areas or unfinished portions of the addition may also be considered potential living area and/or bedrooms.. d. The partitioning of basements may result in the added rooms as being considered potential bedrooms. ` e. The renaming of a bedroom may not necessarily negate its potential use as a bedroom and will be considered on a case by case basis by the Department. f. Rooms which will not be considered a potential bedroom must meet one of the following criteria. i. If the room has a floor area less than 70 square feet. ii. If the room has a horizontal dimension less than 7 feet. iii. If the room in question can only be accessed through another room with no other means of potential egress, one of the rooms will be considered a potential bedroom, if the dimension criteria for a potential bedroom is met or exceeded by one or both rooms. g. For houses with current code SSTS's, excluding repairs, which were approved without a waiver after December 31, 1989, the Department will allow the following rooms on the first floor of the house: li ving room, dining room_Citchen, family room and ___ . -hom'C -efiiva /study.. Any_adier-rooms. 'u :yOnd~ those- listed z i r rE - _ _ ...... will be considered a potential bedroom except for rooms which meet the criteria in item' i'. 9. Any addition which does not result in an increase in the number of bedrooms will require the submission of plans (to scale), prepared by the property owner, showing the entire existing and proposed house floor plan with each room labeled. Once the review has been completed, the plans will be stamped by the Department noting the number of bedrooms, including potential bedrooms. If the number of bedrooms remains the same as existing, no further expansion of the SSTS will be required, .provided the existing SSTS is functioning properly. The Department will issue a letter indicating the total number of existing bedrooms and that no expansion of the SSTS area will- be required and that any other permits or variances required are the jurisdiction of the local municipality. If however, it is determined that an increase in potential bedrooms is proposed, then refer to #b on the previous age, Any previous repairs which have been done on the SSTS which do not meet current code requirements do not count towards the SSTS capacity when an addition increases the bedroom count. 10. The existing SSTS must be functioning satisfactorily for an addition approval to be granted by the Department. 2. �I 11. The SSTS design flow for additions that show multiple kitchens, existing or J / proposed, will be increased by 200 gpd for each additional kitchen over one. 1 12. The legal bedroom count form must be completed by the Town Building Dpp�ftcnt, even in the r�se:where: .Ce.r-tifi.cate-of Construction Compliance- has been issued by the Department. Any addition not covered in the general outline above will be handled on a case by case basis. 3.0 SUBMITTAL PROCEDURES Prior to the construction of a building addition, plans for the proposed work must be reviewed and approved by the Department. The submission requirements for an addition permit are as follows: a) Addition Application (Appendix A) b) ' Permit application fee of $100.00 (Certified Check or Money Order made payable to Putnam County Health Department). Note, if the addition application requires a new SSTS, the fee is $500.00 ($100.00 for the addition application plus $400.00 for the SSTS review). c) One (1) set of house plans, drawn to scale, showing only the existing conditions. All living areas, including basement, are to be shown on the plan(s). The use and dimensions of each room are also to be provided on the plan. The plan is to include the applicant's name, street address, town; and tax map number. Please refer to Appendix C for an example. The plan does not need to be prepared by a design professional. d) Two (2) sets of house floor plans, drawn to scale showing the proposed building addition. All living areas, including basement, are to. be shown on e plans. The- F........�,.... ,... -�.. _....... _......, ..... _ 1?. �.. „. _..,pse an..-..,.,. dimensions, of eac room are also to be provided on the plan. The plan is to include the applicant's name, street address, Town and tax map number. Please refer to Appendix C for an example. The plans do not need to be prepared by a design professional. e) The "Town Legal Bedroom Count and Proposed Addition Status” form (Appendix B) is to be completed by the Town Building Department. fl A copy of the property survey showing the existing house, well and SSTS and proposed building addition, drawn to scale. 3. T �� �. %t .. .. .�.. .v.. - �- .. - . �. .� ... -. r -. .- � _ _�� b.. � .. u�... .• -. • T.�.s; -iV �W ALLEN BEALS, M.D., J.D. Commissioner of Health ROBERT MORRIS. P.F,.. 'birecfor of26_ironmental Health DEPARTMENT OF MA.RYELLEN ODELL County Executive i�►� `�� OF Geneva Road, Brewster, New York 10509 Phone # (845) 808 -1390 Fax # (845) 278 -7921 ADDITION APPLICATION RESIDENTIAL ONLY STREET 0 l� 96 �J�Yicl e. TOWNLqKe CeL<Js UJ TAX MAP # . NAME �I�b�710 ���rrka PHONE(21 ,q) L(—1 a 3 PCHD# "" �3 MAILING ADDRESS 101 V'n ee_ hJ • P 10566 DESCRIPTION OF ADDITION *NUMBER OF EXISTING BEDROOMS vZ NUMBER OF PROPOSED NEW BEDROOMS O * (FROM CERT. OF OCCUPANCY OR CERTIFICATION FROM BUELDING INSPECTOR) "Any addition which is considered a bedroom requires formal approval of plans (Construction permit) prepared by a Professional Engineer or Registered Architect in accordance with applicable sections of the Putnam County Sanitary Code. Please submit this form and the following to Putnam County Health Dept., 1 Geneva Rd, _ :Brewster, -NY: 11i509,.Phone::(845808 =1390, . 1. Certified check or money order for $100.00. 2. Sketches of existing floor plan (drawn to scale, all living area including basement, to be shown and dimensioned and use of each room specified). (See Section 3.c of Bulletin HA -1) 3. Two sets of proposed floor plans (drawn to scale — with name, street and tax map #) A# * Non - professional sketches are acceptable and preferred. (See Section 3.d of Bulletin HA -1) 4. Copy of survey showing all well and septic locations on the subject property to the best of your knowledge. Include date of installation known. Contact this office with any questions. 5. Copy of Certificate of Occupancy from the Town or Certification from the Building Department with legal bedroom count of dwelling. OFFICE USE COMMENTS 4. I' . • •. • � d � .. • --' • •..: d G' � . � .r . \(.. •.�.. r. .- 2 �. J . . • .: r ♦ ,1 w ... . � ...V G ' >� - .i .� .. i1 .J � r p •I APPENDIX C :ERTIFIED TO: JOSEPH 3, tLIZA11El H IVI"KEON t e V ACCORDANCE WITH THE EXISTING CODE OF PRAC- «i i r' ICE FOR LAND SURVEYS ADOPTED BY THE NEW YORK /Vow Or Fori77erl R,;chard & y Renee Danfe TATE ASSOC. OF PROFESSIONAL LAND SURVEYORS. / Story . o Stucco: Nou5e 65 I N / F Gone. �,' •' , �\ r Due East I O3 t^C1tlO o. Stockode .! 128.56' Fence 0.6'E. D I D Z Picket Fence o pvc S•e f41c N (ll % N ¢ � G° On OD I V, 3 33 9' 64 0 0 122 t i rn O Pz Story O Frame House 0 O 3 We %� o y l23 � • I o 23.5' ! %It " O -4 � D It V1 Pick 5.0•' . hrm. 4.6 t Fence O. 6' Stockade Fence 2. 7' p.91 �C Due we-s- i O e 127.58' 0.31 w. -, O = : Conc. n •: AREA = $, /ZZ S Now or Formerly Frank sL/ Manzeila & Warren Maeline :.r O. /lBAC. P h h b L`t 63& SURVEY OF PROPERTY rem/ses s own ereon e /ng p s 64, Block 3 as shown on mop of "Lake slruArE A7' Peekski // - Sect /or7 sold mdp filed LAKE PEEKS A014 L in fhe fufnam Counfy Clerk's Office on Moy 28, 1929 as Mop No. 185. TOWN OF PUTNAM VALLEY TNA M COUNTY, IV. Y. Certifications shall run only to those individuals and institutions RU _ shown hereon under the title policy No. shown above. Said certi- ' lications are.not transferable a SCALE : /"f /5' DATE : 5c PT. B, 1966 SURVEYED & PREPARED BY s BUNNEY ASSOCIATES LAND SURVEYORS RURAL ROUTE #2 FIELDS LANE NORTH SALEM. NEW YORK 10560 f+ - e"- -_ t SURVEYED AS IN POSSESSION FILE No. T 733 - 2/ N T L.0 Na 49332 - 2' «i 4 , aaf'� 1. 0 `i Y j I Ll r/' EXISTING O STORAGE SHED +' 11 TO REMAIN lJ 3) EXISTING 1 STORY FRAME I i 4� f RE-CON UCTED.IN -KIND 9 DUE TO FIREt ,-' 7- APPROXI TE ld TION -.1 OF SEPTI�TANK _ o • e e e o e e Ca ® o. � "__,.._ -- ° m v m v o m —�'A PLOT PLAN .P 1/8 " =1' -0" h G SEL URE EXISTING 1 STORY FRAME HOUSEyT k RE-CON UCTED.IN -KIND 9 DUE TO FIREt ,-' 7- IN r •.j APPROXI TE ld TION -.1 OF SEPTI�TANK _ o • e e e o e e Ca ® o. � "__,.._ -- ° m v m v o m —�'A PLOT PLAN .P 1/8 " =1' -0" h G SEL URE /ate ........... 8 /4 ................... .... 19_80. TOWN OF PUTNAM VALLEY N980-5380 Zone District .... ....... � .......................... PERMIT RECORD Application is hereby made for .......... SA.....TARY ............... .............. ; ....................... ........ ..Permit Work io start ..... A, T .. ONCZ ..................... Description.,ADP .... I .... MRAOR ... RIT ........... ....... ..... ....... .................................................. .......... .......... ... ..... . ..... ... ... ... . .. .. . . ........................... Location of Premises—Street or Road ........... uu. E, ... Dk.V'E.,s .... TM .... ......................................... .. . ............ ... SEC. ........... A ....... BLOCK .......3 ................. LOT ........................... FRONTAGE .................. ......... ............... Depth .. .. .. . ... . ....... Rear ........................... ACRES (other description) or number of squa'rq feet .......... I ............... .. . ............................... - ..... ................. ....... ; ...... ;1 ...... ........... I ......................... ....... SUBDIVISIONNAME ..... . .......... . L P ............................ : ........................................................ ...... ........... TEL . ..... .......... ............................. OWNER ... JO.SEPH...MC ... KEON ............................................................... . ADDRESS.LAKE..DR..""LK.. PEEKSKILL. U 'N...Y . ................ Dimension of Building Width Depth Stories Type foundation ....... ........... ................ 1. .................. Size& Use Each ........................ ... ......................... -Room with Window Area ........ ........................................ . ........ . . 11 .. ..... 75ew6riagg j ypq ..... ............. Size of. Septic Tank . ............ . ...... Lineal Ft. Drainage ..................... ............................... Size of Dry Wells ................ ......... .. . . Plbmbing Description ............. .. . ... ......... .. Well Description— ................ ................. ..... ............. Additional. Information ............................................................. z ............. .............................................................................................. ........ �.: .................... 1 .............. 0( a p p I 1 6 p ri, This rn-u-ii�,.,6e,..aicoiWpanie''o""by. a. copy sur'veyor's map and cqM­p'l­ plans, all informiai!'�n.re* �irecl !ate pans, an qu by the :,Uninq Ordinance' a4 Satitar Code '­`of th; 76w d' 6� , . e n of Putnam Valley n y inspector. e r! u ste Estimated Bui' ding Fee $ 11 Tpial. Area �iva6le ........... .......•••. $ .......................... Date. loining Board Approval ... ....... .............. $ ......... .......... .... Plumbing $ ..... ........ ...... ....... Well - — ----- — — — — — — — Sig tune ) Owner( Contractor if corporation, give title- BZ5 .1-77 USE CONST.. ROOFING LAND 1 Family Wood Wood Shingle Paved 2 Family Steel Asb. Shingle Dirt Log 'Cabin Brick, ,, Tile 6ifej:, Bungalow Concrete Metal Swamp A p­artme4 Stone Br66k, Store . FNDTNS. INTERIOR Lake F. Store & Apt. Sfon4­.- Rooms Dams,. Store & Office I Concrete Apt. Rooms Sw. Pools 1011ce, Blocks Apt. Ten. Courts Gas Station -Brick, Attic Open Garage C Piers. Attic Finished.. OTHER BLDGS: EXT. WALLS PORCHES Barns BASEMENT Wood X Front Shacks jPart Brick X I Side- Cottages Full .Brick Va!',,.,, X, Rear Bungalows Cement Floor Log X Encl. Electric Finished Shingle misc. Phone Gauge •B:'`In: " ' Comp: Plot Plen `Furnace Field Stone Driveway Dimension of Building Width Depth Stories Type foundation ....... ........... ................ 1. .................. Size& Use Each ........................ ... ......................... -Room with Window Area ........ ........................................ . ........ . . 11 .. ..... 75ew6riagg j ypq ..... ............. Size of. Septic Tank . ............ . ...... Lineal Ft. Drainage ..................... ............................... Size of Dry Wells ................ ......... .. . . Plbmbing Description ............. .. . ... ......... .. Well Description— ................ ................. ..... ............. Additional. Information ............................................................. z ............. .............................................................................................. ........ �.: .................... 1 .............. 0( a p p I 1 6 p ri, This rn-u-ii�,.,6e,..aicoiWpanie''o""by. a. copy sur'veyor's map and cqM­p'l­ plans, all informiai!'�n.re* �irecl !ate pans, an qu by the :,Uninq Ordinance' a4 Satitar Code '­`of th; 76w d' 6� , . e n of Putnam Valley n y inspector. e r! u ste Estimated Bui' ding Fee $ 11 Tpial. Area �iva6le ........... .......•••. $ .......................... Date. loining Board Approval ... ....... .............. $ ......... .......... .... Plumbing $ ..... ........ ...... ....... Well - — ----- — — — — — — — Sig tune ) Owner( Contractor if corporation, give title- BZ5 .1-77 ALLEN BEALS, M.D., J.D. Commissioner of Health ROBERT MORRIS, P.E. Dir7tor of Environmental Health W I- OF HEALTH Geneva Road, Brewster, New York 10509 Phone # (845) 808-1390 Fax # (845) 278-7921 Town Legal Bedroom Count & Proposed Addition Status Re: nn L&V-�� (Owner's Name) Tax Map # Address: -10 Lc— � Dn,6 Town: Year Built: According to ecords maintained by the Town, the above noted dwelling, is in compliance with Town Code. Is not . in compliance with Town Code. The Legal Bedroom Count is- This information has been obtained from: Certificate of Occupancy: -W MARYELLEN ODELL County Executive The plans for the proposed addition are considered: Addition to existing house only Teardown and/or re-build allowed under Town RegWafions Q redamG�,Ce)- [2b Building Inspector Date 5. , i i i I I ' • �' ' _ . _' .._.; : � +yJ._m.� .f�.Cltt!lr�n? (�a /� __i_+_ ..' . -_ .- - -- • -- � - I _.j _ I ' V , + 0 1 I , _ , I I j• I , _ , I r • t f I I I ; f � I 1 , w + I ' iI , Q i { j I ' I I ! � I t I I ! I ' I, I I i ' I {- ! I •I I `�• j I i , j I • /� , I f' j I L fit•;'' ,I�1 Name & Relationship (iae, owner,tenant, etc.) TYPE FACILITY in (include sketch locating all adjacent wells) - WM: Repair must be in same location afid of same type as original sewage disposal system. Different location may require submittal of proposal from licensed professional engineer or registered architect. VJCLL -t Proposal approvel�� Proposal Disapproved inspector's Signat Fe & Titl romsal awroved with the following conditions: to Procurement of any Town permit, if applicable. 20 Submission of as built repair sketch in duplicate showings ao owner's name. bo Site Street Imo, Town and Tax Map number. co Location of installed components tied to two fixed points do System description (e.g., 1250 gale concrete septic tank, drywells surrounded by one foot + gravel). ea Installer's name and number. (eoge,house corners). three precast 61 diamo x 6° deep 3. System repair to be performed in accordance with the above proposal and conditions. I, as owner, or reported jagent of owner agree to the above conditions. SIGNATURE / - ✓ _. °... /C1�- �i:.(J' - MU -�;L�/�i� �. _ ..�,i,�_i -� 3 s Vhibe (PUD)o YeUcw (fin P(U; Pink (,Applicant) ------------- !liill� C7 Lake Drive TX Lake Peekskill, N. Y. ng Specialist of EASTERN STATES SEPTIC CO. TRENCHING DIGESTERS ANY TOWN OR STATE —T' 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 Owner & Operator OIL STORAGE TANKS INDUSTRIAL SLUDGES ------------- !liill� a. LAkeland 8 -6842 Cleaning Specialist of DIGESTERS. IMHOFF TANKS SEPTIC TANKS CATCH BASINS BOOSTER PITS OIL PITS OIL STORAGE TANKS INDUSTRIAL SLUDGES t Lake Drive Lake Peekskill, N. Y. EASTERN TES S PT0C 09. "f 1' TRENCHING ANY TOWN! OR STATE DRAINAGE BEDS SEPTIC TANKS K. R. LIETZ & SONS CESS POOLS INSTALLED Raymond K. Lie #z & Kenneth J. Liefz ' CITY DIS. PLANTS Owner & Operator °l i Sys. !v OWNED SITE MAIL' PERS( DATE Name & Relationship (i.e, owner,tenant, etc.) TYPE FACILITY PHONE Proposal (include sketch locating all adjacent wells): NOTE: Repair must be in same location afid of same type as original sewage disposal system. Different location may require submittal of proposal from licensed professional engineer or registered architect. VEIL � • Cam., : �l� %�:.rX�.P� -� / J 1' R¢s 1 t e �. Proposal approved,/e�' Proposal Disapproved Inspector's Signature & Titl � Date 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 ccmponents 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 reported agent of owner agree to the above conditions. SIGNATURE _ / /�� TT_Tf F _ . _? ; >/� F -.; h _ : LINTS IMM: WAte (ICHD); Yellrw (Tan HE); Pink Qgiiamt) SITE MAIL: PF:RS( DATE Dame & Relationship (i.e, owner,tenant, etc.) �iTYPE FACILITY / l/ l n n Y1 �1 X U1/�.� PHONE Proposal (include sketch locating all adjacent wells): NOTE: Repair must be in same location afid of same type as original sewage disposal system. Different location may require submittal of proposal from licensed professional engineer or registered architect. �� kE4L P/,11 7 /?2) H'a"Uz . Proposal approved ( / Inspector's Signature & Ti R Hr X)5 e 11 f�l' O 'l -1- t- zz, Proposal Disapproved Date 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 61 diem. 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 reported /agent of owner agree to the above conditions. SIGI�TURE TITLE �-1L�_ TA _ ._ -.. - -. MF.Se Trite (PQI)); Yellow (Tom BI); Pink (Applicant)