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HomeMy WebLinkAbout0232DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 4.19 -1 -11 BOX 3 00041 !7-- '�`� ' o Ll '� . r . ' loirmi f, or No or 16 ,r{ E , No r i No A+L-.! or fe- 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 ri �y CtA #W Qbt, l fADA box C Y t� IV I. ur GTu� OAA46t e,%q, ? 3e1 @Z Wit C'owar�,2.1:1. , '3.7 �u�s T' 6*tvk um 1 < to �i .K`irr y t a '4