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BOX 31
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OWNER'S NAME ✓o
PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
PROPOSAL FOR SEDGE DISPOSAL SYSTEM REPAIR
;216 use
SITE LOCATION o�;Li,p,
MAILING ADDRESS A
PERSON INTERVIEWED I0/n
f,, Name &
DATE A /16 f7, in
n��L+ i n� mnr -r.ro '621-9.
J-97
i
?A 6OLD PCHD Complaint #
elationship (i.e, (wn tenant, etc.)
TYPE FACILITY i i 6&)C.6—'
C) -1 l PHONE d@6--d %/-✓S
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. _- _ _ _ _ _ _ . . _ At. _ I _
...-. 1
ture & Title
proposal Disapproved
5ode-
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' diem. x 6' deep
drywells surrounded by one foot + gravel).
e. Installer's name and number.
3. System repair to be perfom ed in accordance with the above proposal and conditions.
I, as owner, or a t of comer agree to the above conditions.
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SIGNATURE TITLE
C a� DATE o?
r �
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FM White MD); YeUcw (Tam EI); Pink (k#imnt)
0
a
aC o ;r< II Offices:
Inc. 914 -225 -2745
9� 4- 232 -8888 ah,, New kork S0s3�Onar Glla ay Road- Kato,,
914- 737 -8686
December 30, 1996
Putnam County Dept. of Health
4 Geneva Road
Brewster, N.Y. 10509
Attention: Mr. Robert Morris, P.E.
RE: RAGUSO SEPTIC REPAIR
Dear Mr. Morris,
Thank you for your letter of 12/20/96. I have enclosed the permit form as
requested along with the as -built drawing showing the well within 200' of the repair.
Thanks for sending me additional permit applications as well.
Sincerely,
Frank J. Rice
President
FJR/me
file (PHDEPT)
13
c.
RAGUSO
2 WILLIAM STREET
PUTNAM VALLEY, N.Y.
o WELL
A
AS -BUILT SEPTIC EXPANSION
12110196
#4 EXISTING SEPTIC TANK
81 SEPTIC
#3 TANK
BOX 5
#6
78 ,, 87
LEACH PITS w1STONE
A
B
C
1
13'
52'
2
36'-
48'
3
17'
57'
4
29'
5'
6
81'
34'
7
33'
59'
d-
am
a -3; % -3 -J'c9
PHCNE S'
SITE I=TIORI l/Uy //� %%���-i�%5/- ✓ cl %T' �/� / /,� / �q#
MILING ADDRESS
PERSON INTERVIEWED PCHD Complaint
Dame & Relationship (i.e, owner,tenant, etc.)
DATE �2 G 767 TYPE FACILITY
PROPOSED TALLF,[t PHCNE
�---� ✓1 H.� f --e iTiG•�� 5 � � /S a�
Pro (include sketch locating all adjacent wells):
WME: 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 &
Da
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 So diamo x 61 deep
drywells - surrounded by one foot + gravel).
e. Installer's name and number.
3. System repair to be perform in accordance with the above proposal and conditions.
I, as owner, or reported agent of owner agree to the above conditions.
SIGNATURE 6- .55 G' TITLE MTE
Tit
WPM to (F V ® YeUcN M30 HE); Pink (k#imnt) // . /a ----7 / j G
r
OWNEE
SITE
MAIL]
PERS(
DATE
e r4=
TYPE FACILITY
PHONE
Proposal (include sketch locating all adjacent wells):
NOTE: Repair must be in same location and of same type as _original sewage disposal.system.
ni ffcrcn+- may .aiiiTni +-,F,M1 rnf
Proposal approved Proposal Disapproved
C2 -0)5— 9 /
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' 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 owne or reported age n iof owner agree to the above conditions.
SIGNATURE 0 '14— TITLE 1a1 in 4 r DATE .�� �� O 7
mss: fnhitie (SID); YellAw ( BI); Pink,_ plicant) 3 �7
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J. R. IANNACE
LANDSCAPING & EXCAVATING, INC.
RFfU b, !i0'X 504A-a -CAF2NiELE,"NY''T 0 512"'
(914) 225 -4421
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