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PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
150
PROPOSAL FOR SEWAGE DISPOSAL SYSTEM REPAIR
OWNER'S NAME �,' l _ a. f h 51""M PHONE "$1
SITE I=TION 410f:j St 1°�1f-±ef'S O �? TO
MAILING ADDRESS
PERSON INTERVIEWED PCHD Complaint #
Name & Relationship (i.e, owner,tenant, etc.)
DATE % 2 1 11q 3 TYPE FACILITY
PROPOSED INSTALLER /� �' %,� / fib /Z i '/7 PHONE �S5 •S /d
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.
/U d .f,'o� Gl�`A- yG Y 3` l'i' %fe
a� /� /c-c± R �'�• /� /2 i /' /I/� � c,��� vv r `7f h et ty /Z) e+. /,;Cz,74P
Proposal approved Proposal Disapproved
/2-11, �-71�
Inspector's Signature &.,.Ti , e Da
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roposal 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 Strut 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
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, or reported agent of owner agree to the above conditions.
SIGNATURE
OPM: White (PLED): YeU cw (Tam HE); Pink (Awlicant)
TITLE DATE
BOB BRILL
Owner
n. r. D M I L L r—A%.PM V M I I I'm %X
Land Clearing • Drainage * New Septic & Repairs
Drive Ways New & Repaired • Larg4;& Small Deliveries of
Sand, Stone & Gravel • Snow Removal & More
Visa & Mastercard Accepted • Over 15 Years Experience
RD 2 Box 506, Pawling, NY 12564.,
(914) 855-5610
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RD 2 Box 506, Pawling, NY 12564.,
(914) 855-5610
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