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BOX 36
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PUTNAM COUNTY HEALTH DEPAR'IlMENr
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
PROPOSAL FOR SEKhGE DISPOSAL SYSTEM REPAIR �a
CC'S NAME Lewis PHCNE 52£; -779£3
SITE LOCATION 21 Sunnyside o Lake Peekskill,NY 7K#
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PEON INTERVI15M Owner PCHD Complaint #
Name & Relationship (i.e, owner,tenant, etc.)
DATE TYPE FACILITY
PROPOSED INSTALLER A• Sup i no and Sons PHONE 962-5-985-
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 from licensed professional engineer or
registered architect.
S1V eX- /5Ati% 1zo9&AV
Proposal Disapproved
Dater
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 camponents tied to two fixed points (e.g.,house corners).
d. System description (e.g., 1250 gal. concrete septic tank, three precast 6' diam.
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.
[, as owner, or reported agent fawner agree to the above conditions.
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;IGNATURE TITLE DATE
x 6' deep
W: V&be (R'I'D); YeUcw (Tam EI); Pink O plicant)