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BOX 31
04063
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MAILING ADDRESS
PERSON INTERVIEWED Az /,o
Name &
DATE "5 > ,- i
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PHONE
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94re�,- v--;> PM Complaint #
(i.e, owner,tenant, etc.)
TYPE FACILITY
�- PHONE
Pro (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
Inspector's Signature & Title
Proposal Disapproved
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
d. System description (e.g., 1250 gal. concrete septic tank,
drywells surrounded by one foot + gravel).
e. Installer's name and number.
� 2
to
(e.g.,house corners).
three precast 6' diem. x 6' deep'
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.
SIGNATURE4/�' .� �, �� TITLE
-MS: V&be (PC W; YeUaw Mkm 8I); Pink (Applicant)
DATE
PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENrAL HEALTH SERVICES
1 1
P'• 9; �1• 1
OWNMIS BUM Mrs. Thelma Doebbler PHONE. 962 -4488
SITE LOCATION 72 Lk Drive East, Lake Peekskill, NY 10537 �q
MAILING ADDRESS (same)
PERSON INTERVIEWED Owner PCBD Complaint 0
Name & Relationship (i.e, owner,tenant, etc.)
DATE June 16, 1988 TYPE FACILITY Single Family Residence
PROPOSED INSTALLER Owner PHONE 962 -4488
W �l�l,l � VVLL 1(i
Proposaljinclude sketch locating adjacen wells):
NOTE: "'Repair must be in -same locatio and of same type as original sewage disposal system.
Different location ittay r®quire sulxnitta of .P sal from licenses professional engineer or
°s
ture & Title
pr000sal approved with the following conditions:
1. Procurement of any Town permitr if applicable..
2e Submission of as built repair sketch in duplicate showing:
as owner's name.
bo Site Street Name, Town and Tax Map number.
ce Location of installed components tied to two fixed points
do System description (eogor.1250 gal. concrete septic tank,
drywells surrounded by one foot ¢ gravel).
eo Installer's name and number.
,��Try/
(eogo,house corners),
three precast 66 diam. x 61 deep
3. System repair to be performed in accordance with the above proposal and conditions.
I, as owner, or reported agent owner agree to the above conditions.
SIGNATURE TITLE Engineer DATE June 23, 1988
OPM: Wiite (PCED) ® Yellow (Tom ffi) ® Pirk (Aniiamt)
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Proposal approval T��� Proposal jDpp7r o ved
r r` A W _I loos .Ovid t_ `rAjV, -��� �
°s
ture & Title
pr000sal approved with the following conditions:
1. Procurement of any Town permitr if applicable..
2e Submission of as built repair sketch in duplicate showing:
as owner's name.
bo Site Street Name, Town and Tax Map number.
ce Location of installed components tied to two fixed points
do System description (eogor.1250 gal. concrete septic tank,
drywells surrounded by one foot ¢ gravel).
eo Installer's name and number.
,��Try/
(eogo,house corners),
three precast 66 diam. x 61 deep
3. System repair to be performed in accordance with the above proposal and conditions.
I, as owner, or reported agent owner agree to the above conditions.
SIGNATURE TITLE Engineer DATE June 23, 1988
OPM: Wiite (PCED) ® Yellow (Tom ffi) ® Pirk (Aniiamt)
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