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PUTNAM COUNTY HEALTH DEPARTMENT
DMSION TOF' _ ENVIRCNMENIAI, HEALTH SERVICES
225 -0:310 _.,
PROPOSAL FOR SEWAGE DISPOSAL SYSTEM REPAIR —Af
OWNER'S NAME 0 DA - 7y � o) c Z PHONE 7
SITE LOCATION "� /-A Ift 1 24# '-
MAILING ADDRESS C13 (:,k S /z /Zz %VI
PERSON INTERVIEWED 0 n! :lz PCHD Complaint #
Name & Relationship (i.e, owner,tenant, etc.)
DATE Y v 0a S , ) qq l - -- - TYPE FACILITY
PROPOSED INSTALLER x- h►�� � l�/ CA i: z PHONE 5-a 19' � CP 4� 2)
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.
s Sianature
Proposal
with the following conditions:
J ,
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 r ported� agent o er agree to the above conditions.
SIGNATURE ° ' TITLE (_'0'VI��c'6 i!i DATE
DPIM: r6i to MD); Ydlcw \mil HE); rink Lk#jcwt)
1.4` cl8 -6842
Lake Drive
Lake Peekskill, N. Y.
'`leaning. Specialist of
TRENCHING
DIGESTERS DRAINAGE BEDS
IMHOFF TANKS ANY TOWN OR STATE
S 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
OIL STORAGE TANKS Owner Operator
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INDUSTRIAL SLUDGES
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PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF. ENVIRONMENTAL. HEALTH SERVICES .
225_0:310
PROPOSAL FOR SO&GE DISPOSAL SYSTEM REPAIR
t � � r LA B I S PHCNE s� �- d� 7
owNER's NAME 71 � A - -1--i
SITE LOCATION
MAILING ADDRESS L/a (-Nc
/Ll N.
To .1/0-/- :��
PERSON IN'T'ERVIEWED p w,,JZ /l PCHD Complaint #
_ Name & Relationship (i.e,.owner,tenant, etc.)
DATE �,►._ S , TYPE FACILITY /
PHONE S"a. 9- D cpq .2 .
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.
Proposal approved
s Sianature
Proposal
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 canponents tied to two fixed points (e.g.,house corners).
d. System description (e.g., 1250 gal. concrete septic tank, three precast 6' d.iam. 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.
L, as owner, or rgported, agent o er agree to the above conditions.
SIGNATURE TITLE ('0- ('J /7 DATE
.M: *dbe (PGD); Yellow (fin BI); Pink (A iicant)
Lake Drive
Lake Peekskill, N. Y_
cialist of EASTERN STATES SEPTIC C._. Y TRENCHING
:RS_. = ,.�: -..r . DRAINAGE'BEUS
ANKS ANY TOWN STATE
x
r i ic. i ANKS
SEPTIC TANKS
'CATCH BASINS K. R. LIETZ & SODS CESS POOLS INSTALLED
BOOSTER PITS Raymond K. Lieta & Kenneth J. Lieta CITY DIS. PLANTS
OIL PITS Owner. Operator
OIL STORAGE TANKS
INDUSTRIAL SLUDGES
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