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..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 sukmittal of. proposal fran licensed professional, engineer or
registered architect,
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Proposal approved_
Inspector's
Proposal Disapproved
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*Wosal,approved with the following s
conditions: As l / D' '
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' diam. 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 owner, or reported agent of owner agree to the above conditions.
SIGNATURE TITLE
OFFS: Mite (PQD); Yellow (Tam HO; Pink (Afplianit)
AP._tCATION - UL) ITLON - (RESIDENTIAL ONLf
Name: 1°i�� ,` Olc �.r°� Phone %/V �l Year of Cr-ginal
S7. �%4,,aJl�r'U c° .�, TM# Construction
Mailing Address' 01Ur' Town
Description of Addition /9 I` �--
Please submit this form and.the following to PUTNAM COUNTY HEALTH DEPARTMENT, 4
GENEVA ROAD, BREWSTER, NY 10509, Phone 278 -6130 with the following information.
Number of existing bedrooms_ Proposed number of bedrooms_
A] Square Footage of existing house
B] Square Footage of Proposec Addition c�'
% increase in floor area ( A divided by B) X 100)= r
IF THE PROPOSED ADDITION IS GREATER THAN 15%
CHECK for '$100.00
Sketch of existing floor plans (all living area including basement, if any)
Non- professional drawing
---'3: Sketch of proposed floor plan.
Non professional drawing
4. Copy of survey showing well and septic location, to the best of your
knowledge. Include date of installation if known." Any questions please
contact Wi 1 i i am Hedges or FaberMor= r-.is.
I= THE ADDITION WILL RESULT IN AN ADDITIONAL BEDROOM THAN
1. CHECK for $100.00
2. Sketch of .existing floor plans (a.11 living area including basement, if any)
Non - professional drawing
3. Sketch of proposed floor plan.
Non professional drawing
4. Plans for the Sewage Disposal System prepared by a Professional Engineer
meeting present code requirements, may be required.
F'JTNAM COUNTRY HEALTH DEPT. APPROVAL IS REQUIRED.
OFFICE USE
Ccmments and /or conditions
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Approved by :,O! TITLE
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