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83.82 -1 -43
BOX 32
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04261
PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
OFFICIAL USE ONLY
`05
SITE LOCATION Z9 LAV. TM# 8182- 3
OWNER'S NAME tea? a tifo 0245-:4z )-V_A r #V C_ PHONE -7I � —9,3Y1171
MAILING ADDRESS cf (p Ceoy_ j°. Oli�ly m2�7�1
PERSON INTERVIEWED de w - e r .� PCHD Complaint #iJ 1
Name a ations in i.e., ovI tenant, etc.
DATE > � �
TYPE FACILITY fi% -gei:�i ose e
PROPOSED INSTALLER Te)]> PHONE
ADDRESS 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.
Rpw9 nl 6 ttF�
J,, as Qwne ,_pr. reported a e t ,o owner agree- to- the.conditions, stated oi� ;thia form.. - r.
SIGNATURE TITLE_ DATE L5 `s-
4
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.
Proposal 9 ed
V
Inspector's Signature & Title
COPIES: White (PCHD); Yellow (Town BI); Pink (applicant)
PC -RP 99NM
DATE
273 Starr Ridge Road Tel. (845) 278-6212
Brewster, NY 10509 Fax. (845) 278-0403
April 6, 2005
Mr. Robert Morris
Putnam County. Department of Health
4 Geheva Road
'Brewster, New York 10509
Re: 129 Lake Drive - Lakeside Deli
Town of Putnam Valley, New Yrok
Rv Map 83.82-143
Dear Mn . Morris,*
Our Client, Entran Realty who OYMS the above location, would like to upgrade the existing sewage
treatment system servicing the above location.
Enclosed pleasefind a COPY of the following items for your review and approval:.
• Proposalfor sewage Disposal System Repairlupgradeform.
• Plan and Profile Sewage Treatment System dated 415105 by Beyer & Associates..
I trust the above materials are adequate for Your approval, and, complete the submission for the above
have any q I tions concerning, this project,, please do not hesitate to call me.
How.'eve r if you ues
Very truly yours,
Mich-ael Beyer, P.E.
Project Manager