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PUTNAM COUNTY HEALTH DEPAR24M
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
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PROPOSAL FOR SEWAGE DISPOSAL SYSTEM REPAIR t
OWNER'S NAME l•! SS y `s,� /— G %�°� ,� t-- S PHONE
SITE LOCATION 5� y� h s o j`' �O �— —Z_
MAILING ADDRESS z Il
PERSON INTERVIEWED PC HD Complaint #
Name & Relationship (i.e, owner,tenant, etc.)
DATE TYPE FACILITY
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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. /
Proposal approved _
Inspector's Signatures&
Proposal Disapproved
Proposal approved with the followinq conditions:
Date
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 6' diem. 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
SIGNATURE
IP1E`S: White (PCID); YeUcw (26-pn. flI); Pink (Ani iamt)
to the above conditions.
TITLE DATE
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�RVEYEO a PREPARED BY
BUNNEY - ASSOCIATES
E e & SURVEYORS
`56 KATONAH AVE.
K ATONAH, NEW YORK
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c •, au; s_ SURVEYED AS IN POSSESSION FILE P10.T931 ?
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Clete Site Development P.O. Box 226
Shrub Oak
New York 10588
PUTNAM CONTRACTING
2-7>
Date-
Project: 01� �LJSA