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PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
PROPOSAL FOR SEWAGE DISPOSAL SYSTEM RFPAjR
OFFICIAL USE ONLY
-c)3
SITE LOCATION �i % a �� %� �� TM#
OWNER'S NAME – /-/2 /22 d PHONE
MAILING ADDRESS , / � i ,i
PERSON INTERVIEWED Q' PCHD Complaint #,
Name & Kelationship i.e., owner, tenant, etc.
DATE �° ® TYPE FACILITY
PROPOSED STALLER —. P PHONE
ADDRESS 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.
ve
I, as owne7ororted a ent of owner agree to e c 'bons Tated on ts form.
SIGNATURE l'YZ ` 5�a TLE � 2 � i DATE
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 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
e., Installers' name and number.
3. System repair to be performed in accordance with the above proposal and conditions.
Proposal approved
Inspector's Signature & Title
COPIES: White (PCHD); Yellow (Town BI); Pink (applicant)
PC -RP 99ML
APPLICATION - ADDITION - (RESIDENTIAL ONLY)
d; R � // Name: ,LT �t i SfP�� Phone � W�3�2_ ear of Original
Street 1g, is ���/ /2 ( TM# Construction
CJ Gd G `�'C� r
Mailing Address S 7 Town PCHD PermiL G
Description of Addition --e.,.-j z -+ Q�
OF � 7,-e,-. / st -7 /,-z,27
Number of existing bedrooms Prcposed numbuer�T bedrooms
A] Square Footage of existing house _�s Gam.
B] Square Footage of Proposed Addition Z 5�
% increase in floor area ( A divided by B) X 100
Please submit this form and the following to PUTNAM COUNTY HEALTH DEPARTMENT, 4
GENEVA ROAD, BREWSTER, NY 10509, Phcne 278 -6130 with the following information.
IF THE PROPOSED ADDITION IS GREATER THAN 15%
CERTIFIED CHECK OR MONEY ORDER
l/L %� CHECK for $100.00
,, --- Sketch of existing floor plans (all living area including basement, if any)
-'Non- professional drawing
v3. Sketch of proposed floor plan.
�. �Klon 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 William Hedges or Robert Morris,
IF THE ADDITION WILL RESULT IN AN ADDITIONAL BEDROOM THAN
CERTIFIED CHECK OR MONEY ORDER ;
1. CHECK for $100.00
2. S�.etch of existing floor plans (all living area including basement,. if any)
Non- professional drawing.
3. Sketch of proposed floor plan.
Non professional drawing
4. Plars for the Sewage Disposal System prepared by a Professional Engineer
meeting present code requirements, may be required.
OFFICE USE
Comment Ord /cr Conditions
S <f N
Approved by:
Date:
cc: BI (T)
addition
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