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4.19 -1 -11
BOX 3
00041
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00041
PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
PROPOSAL FOR SEWAGE DISPOSAL SYSTEM REPAIR
OFFICIAL USE ONLY
Boa
SITE LOCATION 37 Sunset Drive, patterscuz, TM# 4.19 -1 -11
OWNER'S NAME Mr Wi 1 1 i am ['rnnvar PHONE 878 -4529
MAILING ADDRESS same
PERSON INTERVIEWED Mr. Conover (owner) PCHD Complaint #
Name & KelationsHip (i.e., owner, tenant, etc.
DATE 7/28102 TYPE FACILITY Private Dwelling
PROPOSED INSTALLER J. Mantovi Excavating., Tnn _ PHONE 628 -6410
ADDRESS as Kanni riit will ]Rd-, Mahopac NY REGISTRATION#
Proposal (include sketch locating all adjacent wells):
NOTE: Repair must be in same location and of same type as original sewage dispo al system .Different location
may require submittal of proposal from licensed professional engineer or registerec architect. 1
to
I, as own f, rt ed agent of owner agree to the co ' ions stated on this form.
SIGNATURE TITL DATE 2Z 200'Z.._
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
1
MAHOPAC SANITATION SEPTIC, I,NC.
Septic Tank Service
217 Kennicut Hill Road
MAHOPAC, NEW YORK 10541
628 -4526 Joseph A. Mantovi
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