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00542
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PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
PROPOSAL FOR SEWAGE DISPOSAL SYSTEM REPAIR
OFFICIAL USE ONLY
SITE LOCATION �° "` .L ° 4� 2 Z , 7 6 — Z —5
OWNER'S NAME PHONE 22 K - 1 2- Y -7
MAILING ADDRESS S �-
PERSON INTERVIEWED PCHD Complaint #
ame & Relationship (i.e., owner, tenant, etc.
DATE TYPE FACILITY / r' ''"' k
PROPOSED INSTALLER e va-"7 S PHONE (q ) 9 O(. " Y0 7
ADDRESS A W 1' 1 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 fessional engineer or registered arch/it�ect.
//�� 1)
I, as owner, or re rte agent of owner agree to the conditions stated on this form.
SIGNATURE TITLE 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 b, a 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 99NIL
//
DATE
a
PUTNAM COUNTY HEALTH E• • ►• E
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
.PROPOSAL FOR SEWAGE DISPOSAL SYSTEM REPAIR
Cam S NAME Jle-s
SITE IDCATION �'v� aiPn
MAILING ADDRESS
PERSON INTERVIEWED
Name & R
DATE —< /_/ ✓
PROPOSED INSTALLER Cam' r✓/��: F
Gf'./�d'G'��2y PHONE' ;226— la q `%
To 'ev
PC HD 0miplaint #
elationship (i.e, owner,tenant, etc.)
TYPE FACILITY �> Ciro ;c: �i.�•��GY
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 professaional engineer or
- :,registered architect.
®J%v /066 G.gL i��i�1it
Proposal approved
s Signature &
Proposal Disapproved
Proposal amroved with the followina 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. f
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
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 reported agent of owner agree to the above conditions.
SIGNATURE ��� �� / %f TITLE OrlJiVO a DATE 's r r /f w-
, I qTF : 9hite (Pa -D); YeUcw (Tam HO; Pink Lzg2ia3nt)
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GEORGE HARTSHORN
Blacktop Driveways, Paving, Septic Systems
Box 336
CARMEL, NY 10512
(914) 225-9522 (914) 225-8766
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