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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
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�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.
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APPENDIX C
:ERTIFIED TO: JOSEPH 3, tLIZA11El H
IVI"KEON
t
e
V ACCORDANCE WITH THE EXISTING CODE OF PRAC-
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ICE FOR LAND SURVEYS ADOPTED BY THE NEW YORK
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TATE ASSOC. OF PROFESSIONAL LAND SURVEYORS.
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AREA = $, /ZZ S
Now or
Formerly Frank sL/ Manzeila
& Warren Maeline
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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 -
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EXISTING O
STORAGE SHED +' 11
TO REMAIN lJ
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EXISTING 1 STORY FRAME
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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
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1/8 " =1' -0" h
G
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EXISTING 1 STORY FRAME
HOUSEyT k
RE-CON UCTED.IN -KIND
9 DUE TO FIREt ,-'
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APPROXI TE ld TION
-.1 OF SEPTI�TANK _
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PLOT PLAN
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/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.
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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)