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3.20 -1 -71
BOX 2
00122
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PUTNAM COUNTY HEALTH DEPAREMW
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
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OWNER'S NAME I.mbnogno, UavLd'1&po.4Lto, Ronaid* pH� 628 -5416.
SITE LOCATION 47 front kneet, /atten4on, NY enq# 3.20 -1-71
MAILING ADDRESS 385 Nonth Lake Blvd., ahopac, NY /0541
PERSON D R. & p o4 i.t o (Ownen) pCHD plaint #
Name & Relationship (i.e, owner,tenant, etc.)
DATE 4u�uAt 17, 1999 TYPE FP1CILITY l n�vate liweLLi n�
PROPOSED nErA,LER Aahopac San&tatLon .Septi.c, Inc. PHONE 626'- -4526
REGISTRATION # 4/
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.
Rdd two (2i nechaa e/tA
to exLAtLnq A44tem.
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Proposal approved
Proposal Disapproved
Inspector's Signature & Title Da
Proposal annroved 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 components tied to two fixed points (e.g.,house corners).
d. System description (e.g., 1250 gal. concrete septic tank, three precast 6' diem. 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,
SIGNATURE
Q. T I : Vhite (PCB);
Dr-pp a7
agent of owner agree to the above conditions. (,
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