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04707
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OWNER'S NAME
SITE .LOCATION
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PUTNAM COUN'T'Y HEALTH DEPARTMENT
> SION OF ENVIRONMENTAL HEALTH SERVICES (`
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PROPOSAL FOR SEWAGE DISPOSAL SYSTEM REPAIR`
R1 %,4 ;L-/4W /JV IS"'I b CL PHONE q4-5 - S 2 p- 7 o % 6
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MAILING ADDRESS / 3q i / Gy'> - 6 77q &-E
%f V . Y ' / D 5 7 To i t/- a?-'r-060 /-a 34(- con -0000
699L )J-L/. /06-3'Z
PERSON INTERVIEWED PW Canplaint #
Name & Relationship (i.e, owner,tenant, etc.)
DATE TYPE FACILITY,
PROPOSED INSTALLER A 1 %dA1 J6:5,5 NZ TPVCrIO All PHONE gN-737- 4-d, 7 O
REGISTRATION # 40'j ,6 5371-1493 PC 76-R
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.
c1
Proposal approved __ Proposal Disapproved
Inspector's Sionature & Title
with the following conditions:
do-
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 canponents 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
drywalls 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 owner, d e gent of owner agree to the above conditions.
SIGNATUh , TITLE G2 L DATE
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CPS: V&be (POD); YeUcw (Toon ffi); Pink Ggliamt)
. . ........ .
6 3
MOLTON JOSE
CONSTRUCTION -
BLACKTOP - DRIVEWAYS
(914) 737-4270 19
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PUTNAM COUNTY DEPARTMENT OF HEALTH mplaint NO. 8 -1Q
,a COMPLAINT OR SERVICE REQUEST RE R1
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TOWN`r Putnam Valley DATE 05/28/98 REFERRED TO
TAKEN BY B H TELEPHONE —CALLS__ IN PERSON LETTER
CONFIDENTIAL
REQUEST FROM Karl Baisley TELEPHONE28 -9295
ADDRESS Becker Street
ENVYRONMENTAL HEALTH: Sewage Nuisance X Public Health Nuisance
Chemical Emergency. Individual Water Other
CCM HINT OR REQUEST
Failing septic system at 68 Johnson Street — septic in backyard -
1-r
ACTION TAKEN BY
FINDINGS
?.Ob,Lak UP- -3NSPECTI ^N.. (s)
DATE FINDINGS
DATE
FINDINGS
I
DATE
Im
la -k
PROBLEM ABATED -
DATE PERSON NOTIFIED
0.11
ESTIMATED TOTAL MAN HOURS SPENT /
PC- CR
PUTNAM COUN'T'Y HEALTH DEPARTMENT
DIVISION Qf,>Ei�VIROi?AL IiFALTIi :S'FRVL I ^
r.�r: .cam «' =. •,�. ,.a ^Zx'' :.r""5' ».0$:'..d i, n+.. +7. �.'i vco `� = .e'.'.:c�"�:i•r•b:n. 7+-,
PROPOSAL pFOR SEDGE DISPOSAL SYSTEM REPAIR N, 4
OWNER'S NAME fiZ !"�� ; �� T14 f--17�Wy O L
SITE 10CATION
MAILING ADDRESS /
JO/�cJ50� Si. lli // kJ
/-fL--lJi7 67-fie-
053
PRONE 91'�
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PERSON INTERVIEWED PCHD Complaint #
Name & Relationship (i.e, owner,tenant, etc.)
DATE TYPE FACILITY
PROPOSED INSTALLM M14TOAJ C'. AA 9?r,()CrJ6 AJ PHONE
REGISTRATION # 416 -Plc16 5-3-71- Jag 3 PC 7 69
Pro (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 fran licensed professional engineer or
registered architect.
Proposal approved _f.— Proposal Disapproved
s Signature &
rovosal awroved 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
d. System description (e.g., 1250 gal. concrete septic tank,
drywells surrounded by one foot + gravel).
e. Installer's name and number.
. -
(e.g.,house corners).
three precast 6' diam. x 6' deep
3. System repair to be performed in accordance with the above proposal and conditions.
I, as owner, a gent of owner agree to the above conditions.
SIGMA TITLE ���� L DATE
I TP1HS: V&te (RID): Yellnw (fin HI); Pink (Prplirant)