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04713
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04713
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SITE LOCATION
OWNER'S NAME
MAILING ADDRESS
PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
OFFICIAL USE ONLY
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TM# 5
PtIONE &y5- 5-2-00 7, �60
PERSON INTERVIEWED Q-r ►'` 0A- r ►'1a— PCHD Complaint #
Name a atlons ip i.e , owner, t t, etc.
DATE J v K e- Z- � F TYPE FACILITY _
PROPOSED INSTALLER L-�o KrLy 4 d- So k PHONE 1T/4 2,; D/� sy-
ADDRESS ro rt, v, n REGISTRATION#
Proposal (include sketch locating all: adjacent wells):
NOTE: - Repair must tie in same Iocatiori'and of same-type as original' sewage -disposal system -,Dif Brent location-
may require submittal of proposal from licensed professional engineer or registered architect.
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""- � /`� �dd.�. �..� ' �-''� �ErG- tT7✓�°"''` -�' . /�LLL._�.l•J,✓�Y'� ='�=. Lt y. d� G . • ��
W
I, as owner, or re ed age t of er agree to the conditions stated on this form.
SIGNATURE C � i" TITLE 14-Er DATE J U h i
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_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 ` Igo
b. Site Street Name, Town and Tax Map number.
C. Location of installed components tied to two fixed points (e.g.,hous 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 perfo ed in accordance with the above proposal and conditions.
Propos pproved
G/
ector's Signature &Title -DATE
COPIES: White (PCHD); Yellow (Town BI); Pink (applicant)
PC -RP 99NM
Jun 28 05 09:53p Leonardi and Son 914 736 9311 p.2
Well Locations
Owner: Jerry Carra
53 Johnson St.
Lake Peekskill, NY
Contractor: Leonardi & Son Construction, Inc.
PC -560
Cell 914 -980- 554
72
01
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JUN -28 -2005 TUE 21:53 TEL:845- 278 -7921 NAME:PUTNAM COUNTY DEPARTMENT OF P. 2
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OWNER'S NAME
SITE LOCATION
�D
PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
Name &
a
PHONE
TO .
.e, owner, tetfant, etc.'
TYPE FACILITY
,,Ue°iy s A'
a3 4s-
Camplaint #
PROPOSED INSTALLER r �. PHONE y&I Z - 0 EO CD
Pr iinclude 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.
4 o c� C•� /lG
. _ • - iiJ Cry' _ F
Proposal
2.
3.
's
with the
T
Proposal Disapproved
tions:
/ Lt r S lit,
Date
Procurement of any Town Permit, if applicable.
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' diam. x 6' deep'",.,
dryw!ells surrounded by one foot + gravel).
e. Installer's name and number.
System repair to be performed in accordance with the above proposal and conditions.
or . reported
SIGIt7 ( E=
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] idg: %lute MD); Yell& (dal �6; Pink (Aid 1amt)
TITLE �s q/� V� OATE 5/k
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