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83.74 -1 -17
BOX 32
04130
A2
04130
PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
PROPOSAL FOR SEWAGE DISPOSAL SYSTEM REPAIR
OFFICIAL USE ONLY
SITE LOCATION 1 P '.���- &; � �. La�P_ P���k d l TM#
OWNER'S NAME ;1�_ �p a :.� PHONE
MAILING ADDRESS
PERSON INTERVIEWED l; t°' �[��r (��L �p {- PCHD Complaint #
Name & Relationship (L V..' owner, tenant, etc.
DATE TYPE FACILITY_cu
PROPOSED INSTALLER �c'PCC ;Sinn �,c� ��i.- S.nc PHONE p -J
ADDRESS_ = L3 REGISTRATION#
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.
_-C
as owner; qK reporte rt of gree to . the conditionsstated on than fo*m.:
SIGNATURE TITLE �� Si 6PC l� DATE +
_ '"1— ILI — O
Proposal app oved 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 comers).
d. System description (e.g., 1250 gal. Concrete septic tank, three precast 6' diam. X 6' deep
e. Installers' name and number.
3. System repair to be performed in accordance with the above proposal and conditions.
Proposalapproved_
Inspector's Signature & Title
COPIES: White (PCHD); Yellow (Town BI); Pink (applicant)
PC -RP 99ML
�-
ATE
Homeowl
Mr. Mich
16 1D-.-*
AVVI OWUL11
Like Peekskill, NY 10537
(212) 289-5851
Town of Putnam Valley
Tax Map Number: 83.74-1-17
Description of Repair to System:
Existing Concrete Tank
6 Infiltrators with Gravel
Installer:
Philip Leonforte
Precision Excavating Inc.
3 Rochambeau Road
Garrison, NY 10524
(845) 736-0571
Propose�