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PUTNAM COUNTY HEALTH DEPAR7MENTP
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
OWNER'S NAME tr . - 14 �b 11 Ir PHONE P6 -- $W' 2..
SITE LOCATION ,.S�-) (- iii a—. 'OAVZ 6.10 7Ma 37z yao
MAILING ADDRESS 1?0 • 7 rx Z .
DATE
PCHD Complaint #
Name &Relationship (i.e, owner, tenant, etc.)
TYPE FACILITY ��?tbL�+1i?J�}�r
PHONE aW , 606*
REGISTRATION #
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.
WIWI ?.".q .✓c�
Proposal approved
Inspector's Signature &
Proposal Disapproved
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.
Date/
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' 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 ag Opt of owner agree to the above conditions.
SIGNATURE �� =�� n.�� TITLE f/ DATE
.. : indite (PCD): YeLlcw (kwn EI); Pink (AMticant)
House
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3 - 180 Contacts Gally #1
with stone
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Gal�ly #2
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1000gal Septic tank
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Existing Drywell
for Wash machine
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Micheal Alpert ti
South St.
Patterson, n.y.
7 -8 -94
Bottge Septic
Sodom Rd.
Brewster, N.Y.
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. 17"
Bottge Septic
Sodom Rd.
Brewster, N.Y.
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