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4.10 -1 -21
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00181
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SITE LOCATION
OWNER'S NAME
MAILING ADDRESS
PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
PROPOSAL FOR SEWAGE DISPOSAL SYSTEM REPAIR
OFFICIAL USE ONLY
2-1-7 ^-
PERSON INTERVIEWED PCHD Complaint #
Name & Relationship i.e., owner, tenant, etc.
DATE
PROPOSE]
ADDRESS
TYPE FACILITY
PHONE�p -� �® �--
REGISTRATION #�f
Proposal (incldde sket&lFeaffing all a`djacenYwells):
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.
t
?ri Ana e 5 :.5 f z wt m U - Me ie 11 . `i e } h� �(� L A .o i9 a Y� >c� %_
A � c� �� tG�'� /�5 t3;�r 1 � ''PIWA5 Ynu-. - 6e, 6Am w4 fo 4-14:5
I, as owne orted caner agree to the conditions stated on this form.
SIGNATURE TITLE 64 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 comers).
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 pe ormed in accordance with the above proposal and conditions.
Proposal approved
7/2 71erJ 5—
Inspector's Signature & Title p DA
COPIES: White (PCHD); Yellow (Town BI); Pink (applicant)
PC -RP 99NII.
SHERLITA AMLER, MD, MS, FAAP
Commissioner of Health
LORETTA MOLINARI, RN, MSN
Associate Commissioner of Health
DEPARTMENT OF HEALTH
1 Geneva Road, Brewster, New York 10509
Mr. Rooter
75 West Road
Pleasant Valley, NY 12569
Dear Mr. Rooter:
County Executive
July 14, 2005
Re: Repair — Incomplete, R- 177 -05
Gonsalves, 19 Buhleier Rd.
(T)Patterson, TM #4.10 -1 -21
Review of plans and other supporting documents submitted at this time relative to the
above - regarded repair has been completed. The following comment is offered.
1. Due to the proposed alternate location of the septic system this Department
requires a submittal from a licensed professional engineer or registered architect
as noted on the repair permit. .
Upon receipt of a submission, revised to reflect the above comments, this repair
application will be considered further.
GR:lm
Cc: Gonsalves
19 Buhleier Rd.
Patterson, NY 12563
Sincerely,
Gene D. Reed
Senior Engineering Aide
Water Supply Section (845) 225 -5186 Fax (845) 225 -5418
Environmental Health (845) 278 -6130 Fax (845) 278 -7921
Nursing Services (845) 278 -6558 WIC (845) 278 -6678 Fax (845) 278 -6085
Early Intervention/Preschool (845) 278 -6014 Fax (845) 278 -6648
SITE ' LOCATION
OWNER'S NAMI
MAILING ADDR
PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
PROPOSAL FOR SEWAGE DISPOSAL SYSTEM REPAIR
Cry
OFFICIAL USE ONLY
PERSON INTERVIEWED PCHD Complaint #
Name & Relationship i.e., owner, tenant, etc.
DATE /� TYPE FACILITY
PROPOSED INSTALLER �/c n PHONE , f �--
ADDRESS % (� d/ i
0 osa (inc3 e s etang all adJacen 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.
/,Q. -W7f1 ?. - �t"� H P, A F w" i 7 tj &' SUI C n- -7t-'i
I -v
I, as owner orted g.. caner agree to the conditions stated on this form.
,l
SIGNATURE TITLE� DATE X-2-11cy-
T
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 comers).
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 DA'k
COPIES: White (PCHD); Yellow (Town BI); Pink (applicant)
PC -RP 99ML
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MR ROOTER PLUMBING PAGE 02
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JUL -22 -2005 FRI 15:09 TEL:,845- 278 -7921 NAME:PUTNAM COUNTY DEPARTMENT OF P. 2