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PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
PROPOSAL FOR SEWAGE DISPOSAL SYSTEM REPAIR
OFFICIAL USE ONLY
K . G -6 �
SITE LOCATION Wood St 109, Mahomc NY TM# 85.7 -2 -9
OWNER'S N PHONE 528 -4150
MAILING ADDRESS 1()g WOW ci- mahmac- my i nr,a1
PERSON INTERVIEWED E. Ruiz owner PCHD Complaint #
Name & Kelationship i.e., owner, tenant, etc.
DATE Aug. 12th, 2002 TYPE FACILITY Private Dwelling
PROPOSED INSTALLER ,L Mantovi Ex . yatingf Tnr_ �PHONE.
628 -6410
ADDRESS 485 Kennicut Hill Rd., Mahopac NY REGISTRATION# 13 -01
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.
Install (20) Con acttnrs with gravel under & around units.
Install (5) Junction boxes with SDR pipe between boxes.
No closer to well. Same location
:. I, as- owner; or reported °agEnt -af owner.agree to• the,conditions stafedori tt is -form: T _ ....
SIGNATURE f� TITLE QunL A, DATE -OZ
-Pro on sal aRproved 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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PUTNAM COUNTY HEALTH DEPARTMENT
\,�.PIVISION OF ENVIRONMENTAL HEALTH SERVICES
PROPOSAL FOR SEWAGE DISPOSALS S
OFFICIALUSE ONLY
SITE LOCATION W St 109, tLandpac TM# 35.7--2•)
OWNER'S N PHONE 528-•ei1 .50
MAILING ADDRESS L4,34q(p.• Iac JlZ 10541
PERSON INTERVIEWED E. Ruiz (owner) PCHD Complaint #
Name & K%Plionslup (,Ee., owner, tpnrt, elp.)
E'ACILIT'�'PftvAt��
DATE yp i 11i 'la
PROPOSED INSTALLER J. L',Iantoyi Excavatirp, Inc. PHONE
623-6410
ADDRESS 'A3.13 Kanaicut Bill Rd., Mwhopa-c LTZ REGISTRATION4 '13-01 % .!
Proposal (include sketch all adjacent wells):
NOTE:Repair must be,in same location and of same type as original sewage disposal system Diffefent location
may tequire,submittal of proposal from licensed professional engineer,or registered architect.
611 ) . 0 VA ui grave 1 Lu--vler wd 2cs
Llstalll (5) Juriction box0s wi61 SM pi�,-e_ b66yeiall ml�is s .
I, owivri- or4eoorted ag6tdfaikn6r, agree _to,- the cQnditibn,.,; stated _ tW
qq or-rLi.-
SIGNATURE—,' h, t fl. TITLE DATE
Proposal approved with the following conditions:
1 Procurement of any Town permit, if applicable.
2., Submission of as built. repair sketph 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 escription (e.g., 1250 gal. Concrete septic tank, three precast 6' diam. X 6' deep
e. Installs' name and number.
3.. System repair to be performed in accordance with the above proposal and conditions.
-Proposal--.approved,.:-f`''" .,..-
.... . ..... .
3�10
61 q q4
-,Inspector 9-Signature & Title. DATE'.
COPIES: White`(EQ);Ip)
Yellow (Town BI); Pink (applicant)
PC-RP 99ML
MAHOPAC SANITATION .SEPTIC. INC.
Septic Tana Service'
y 217 Kennicut Hill Road q�
MAHOPAC, NEW YORK 10541 wee
628 -4526 Joseph A. Mantovi
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