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83.81 -2 -5
BOX 32
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04227
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SITE LOCATION "olI
OWNER'S NAME_
MAILING ADDRESS
PUTNAM COUNTY HEALTH DEPARTMENT /
DIVISION OF ENVIRONMENTAL HEALTH SERVICES ✓ ✓✓
PROPOSAL FOR SEWAGE DISPOSAL SYSTEMREPAIR'
OFFICIAL USE ONLY
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PHONE q i►- 1- 'i3i��]a(�,
PERSON INTERVIEWED PCHD Complaint #
Name & Relationship i.e., owner, tenant, etc.
DATE TYPE FACILITY ` `no
PROPOSED INSTALLERct�r., �,c�s,x PHONE '31-15 =136- C5`7 1
ADDRESSx Sores,�REGISTRATION# asl;nc ; -
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.
_._Z,.as -ovsi ier,-orxeport t of ee to the conditions stated "on -this form. 41. 05
SIGNATURE G TITLE �(E'S� ��C1� 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 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.
inspector's Signature & Title
COPIES: White (PCHD); Yellow (Town BI); Pink (applicant)
PC -RP 99ML
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`` Homeowner.
eu; lT Danny Loftus
`$ J 168 Westchester Avenue
Buchanan, NY 10511
(914)737 -7286
Town of Putoaan !!alley
Tax Map Number: 83.81 -2 -5
(Description of Repair to System:
Installation of 500 Gallon Plastic Tank
With Infiltrators and Gravel
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Installer:
Philip Leonforte
Precision Excavating Inc.
3 Rocharnbeau Road
Garrison, NY 10524
(845) 736 -0571
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