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0KHM IS NAME
SITE 10CATION
MAILING ADDRESS
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DATE I L -K)
PUTNAM COUNTY HEALTH DEPARIMENr
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
225 -0310
PROPOSAL FOR SFK%GE DISPOSAL SYSTEM REPAIR
PHONE
TO
PCHD Camplaint #
Name & Relationship (i.e, owner,tenant, etc.)
TYPE FACILITY
PHONE ' 1 C)If I
Pro (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.
StQ iii n.f z aC
Proposal approved -X Proposal Disapproved
Inspector's Signat & Title
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' sleep
drywetls 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, o' repor t of owner agree to the above conditions. /'
SIGNATURE TITLE�uLl L1ATE C�V .
OMM: Wiiba (PQ:D); YeUcw (Tam ED; Pink (Afti amt)
`o
PROPERTY LINE -,
'ti L4ca
G►R.� TNle-
WINDOW
t
WOOD
OILTANKI I 1 1 -4- KrralrN
01 0110'r WNK
ACE
WELL
25 GAL P/M OrR P
c
MASTER D -ROO\i
17X12
CLOSE-r(c)
FULL
BEDROOM BA77I
12 X 12
HORSESHOE
I,
PIT
POND
1 W' X 50'
KITCI IEN
18 X 11
BEDROOM LIVING ROOM
15X12 20X12
FROKr DOOR PIcmr WINDOW
BOTTOM FLOOR
BREEZEWAY I GARAGE
12X 12
SI[Iin
II/C TOP FLOOR
ESTER WILLIAMS
no
POOL 16'X 32'
20YR. WARRANTY
HIGHLIGHTS
YR BUYER PROTECTION PLAN
ARDWOOD FLRS UNDER CARPET
RUGS 3 YRS OLD LR & MBR
CUSTOM WOOD KITCHEN CABINETS
Sli►'1'IC
JENN -AIRE STOVE
DOOR
PUMPED EVERY-
2\YRS.
DISHWASHER 2 YRS OLD
LAST 5/90
GARAGE DOOR OPENER
PLUS- VINYL SIDING, ROOF, FURNACE
CLOSET W &D
DA711
i
WORKSIIOP
ONLY C YRS. OLD
KITCI IEN
18 X 11
BEDROOM LIVING ROOM
15X12 20X12
FROKr DOOR PIcmr WINDOW
BOTTOM FLOOR
BREEZEWAY I GARAGE
12X 12
SI[Iin
II/C TOP FLOOR
Owner KAREN PETRUN
Verified Y
PCMLC k 9001706
Addrs. 68 LUDINGTONVILLE ROAD -
Org.PrcS
Direc. RT 311 TO LUDINGTONVILLE ROAD..
Taxes S 3108
7TH HOUSE ON THE LEFT
Town PATTERSON
PropSz 1 ACRE +/-
Area 300 Grid# C14
STYLE
Brs
Bath
Age Gar.
Color
Exterior Tax Map No.
RANCH
3
2
30 1
WHITE
VINYL 13 -2 -2
Floor B
1
1
3
Foyer
C
TV Ant
Apx.Sq.Ft 2000
Liv Rm
X
Deck
Stm /Scr
Sch. Dist CARMEL
Din Rm
Porch
1
A/C
Occupy NEGO
Kit
X
Patio
Sewer
Lake Name
Bed Rm
3
X Range
Y
Septic
Heat OIL Cost
Bath X
X
X Dwshr
W
WtrC /W
Zones2
lav
X Refrg
X
Insulat
EIc:V 220 A100 Co NYSEG
Fam Rm X
X Washr
Survey
Pool:Typ AG Siz 16 X 32
Der. X
X Dryer
X
Sign
Bank,
LaunRnn X
X W /WC
C
Lockbox
Int. Rate
Fr Loc WBS
Bsmnt
IX
SmokDetj
Amt.Mort.
Items Not Incl: TWO SHEDS
BY THE POOL
Amt
Amenities CONY. HWAY,POND,WOOD S.
Remarks *CLOSED BREEZEWAY..IOVELY RANCH IN MOVE -IN CONDITION.
PARKLIKE GROUNDS WITH SPARKLING POND ON PROPERTY.
ROOF, WELL, FURNACE AND HOT WATER HEATER, ALL
FIVE YEARS OLD.
A GREAT MOTHER /DAUGHTER POTENTIAL_.
WOODBURNING STOVE IN THE FAMILY ROOM..... -
CALL THE L!3TING BROKER FOR COMMISSION INFORMATION.
DATA BELIEVED ACCURATE /NOT WARRANTED
Broker C21 VJI. REALTY ( ) Ph 279-5191
S.B.Neg N No 0521
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PETRUN
68 LUDINGTONVILLE ROAD
A,
u1
SITE
PERSON INTERVIEWED PCHD Camplaint #
Name & Relationship U.e, owner,tenant, etc.)
DATE TYPE FACILITY
PROPOSED INSTALLER � i ce,� -e `� c- PHONE
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.
T,
w
Proposal approved Proposal Disapproved
Inspector's Signatures&
Date
roposal 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 canponents 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, or p; agent of owner agree to the above conditions.
DATE TITLE
SIGNATURE � �
CP16: Unite (FAD); YeUc w (T,3,n HU; Pink L112 alnt)
I n - "d -11
Bi-State Inc.
Septic Tank Service
Starr Ridge Road
BREWSTER, NY 10509
(914) 278-7565 (203) 778-4247
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