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00657
PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
PROPOSAL FOR SEWAGE DISPOSAL SYSTEM REPAIR
YES NO • Internal Use Only
❑ Repair Permit issued in last 5 years F1 in Watershed
1.1 Repair within Boyd's Comers, W. Branch or Croton Falls Res.
❑ - Repair within 200 ft. of a watercourse or DEC-mapped wetland ❑ Joint Review
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PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
SITE LOCATION A P� t-I I t✓t_-
OWNER'S NAME •A
MAILING ADDRESS SA iNl f:-;r A, S A 3o
OFFICIAL USE ONLY
(�� I V� - �)q�7-.
TM# 23, 0 9- I -
L
PERSON INTERVIEWED PCHD Complaint #
Name Relationship (i.e., owner, tenant, etc. 1 -
DATE TYPE FACILITY PiOM-C:
PROPOSED INSTALLER Q'.ArV1=D SePTIC- PHONE Q1 - Z Z' /
ADDRESS // )1 WL%QIJ D AVE- �c.vFc2a
fli.� REGISTRATION# �
Proposal (include sketch locating all adjacent wells):
/oSo7 ate'
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.
/N.i 7 /1t- cj i/c /J rid /vGL✓ ie'410 e A , P4AJ-7 1c sEi�i /L 7AN� �
�t't1'7bvL� �Lp ii( iAi�•K. /S �Ct'i CrR�. iYl�?/lC' Gt7t.A i�L`i� j,bvl�- /34
I, as owner or reported gent of owper agree to the conditions stated on this form.
SIGNA � 1
TITLE DATE 2'
Proposal approved with thefollowine conditions:
I. 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.
e. Installers' name and number.
3. System repair to be peyrformed in accordance with the above proposal and conditions.
Proposal approved ✓
- &?-e ` -Sp,
Inspector's Signature & Title
COPIES: White (PCHD); Yellow (Town BI); Pink (applicant)
PC -RP 99ML
X 6' deep
f 1Yg- 7/06
DATE
PUTNAM COUNTY HEALTH DEPARTMENT
brvism OF ENVIRONMENTAL HEALTH SERVICES
PROPOSAL FORS DISPOSAL SYSTEM REPAIR
OFFICIAL USE ONLY
SITE LOCATION TM#
OWNER'S N PHONE
MAILING ADDRESS SAME: A,-S A80JC' 12-S
PERSON INTERVIEWED PCHD Complaint #
--fraine I Relationship (i.e., owner, tenant, etc.)
DATE TYPE FACILITY
C11 4�
PROPOSED IN Q-Qn-SD PHONE
Be-
ADDRESS 311 D /1- VC REGISTPATION# 4-
-7
Proposal (include sketch locating jacent wells):
/V 5"o
Fmg as_-on
NOTE: Repair must be in same locatMon' *ginal S _ ewage disposal system Different location
f
-dfigihe6 r
may require submittal of proposal from licensed professionar o registered architect.
IN S -7,4 1. 1,A—i i,,AJ OLE /vow 10490 -E0o2-7 /4 -7,4AOA—' 1
&p-j(0S-7/,V6- S'00
recur C-T a C.,.- (-&V
I,as.owner ZY orreported gent of oy�per agree to the conditions stated onthis..form.
SIGNA
"a TITLE DATE -"A"7`2
TU
Proposal approved with the following conditions:
1. Procurement of any Town pemlit if applicable.
2. Submission of as built repair sketcl , in duplicate showing:
a. Owner's name
b. Site Street Name, Town and T�-.,Map number.
C. Location of installed components tied to two fixed points (e.g.,house comers).
d. System description (e.g., 1250 go. Concrete septic tank, three precast 6'diam. X 6'd.
e. Installers' name and number.
3. System repair to be performed in accordance with the above proposal and conditions.
Proposal approved v,," -
Inspector's Signature & Title
COPIES: White (PCHD); Yellow (Town Bl); Pink (applicant)
PC-RP 9%E
6
DATE
S'
1
�9�- -T3tJiL�� LO�ATIOIUS s
Se vie fi AJK t l n 2
S-e V-n a 'M4- (ovrleT) 1 ( z
e.■
--
1000 GAL -Pel F.-Y
.SE n77 G. -rA -^JAL. w N-
1APIS X PLAC. o A-
r000 6&L- Mr —rAL. 5CP7i4- 7hAig•
WLXI A7.
pA'ff�o�1 N :1l• t 2�6�
,V6 /0c ..
UNITIED SEPTIC A EXCAVATIOM CORP.
E19 RAILROAD AVE.
BIEDFORD HILLS. N.V. 10607
.V.
Tel: (914) 242 -1999
Fax: (914) 242 -1909
UNITED
EPTIC & EXCAVATION CO".
A Union of Costa & Ferreira, Inc and S.A.F. Septic Systems, Inc.
{Family owned business since the early 60's)
311 Railroad Avemie. BedfordlEUs, New York 10507
phis ;s 4 �Py
—,ee L, E z_-7 /47n le--
/ Z - 7-- a
Street - Town `:= State Zip
y
PERSON IN CHARGE- g
(1R 1NTFR VTFUtTFT) �%ii �?-� S� iG 'Date' ! ! - I 0�
to 0
PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL.HEALTH SERVICES
L
SITE LOCATION 14 1 L-C, Fk 1 . TM# 23. o
OWNER'S NAME M •A 'R-y l /16 X - PH
MAILING ADDRESS SA M a 10-,,S 860
OFFICIAL USE ONLY
PERSON INTERVIEWED PCHD Complaint #
ame Relationship (i.e., owner, tenant, etc.
DATE TYPE FACILITY.
PROPOSED INSTALLER (AI iTt✓'D PHONE
�vFo2a
ADDRESS // 941Le0A Q 1 �I /t t- REGISTRATION#
/oSo 7
Proposal (include sketch locating all adjacent wells):
Cte'
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.
lvi4,L 1400 CA S;�j�
,1' � S - � iiv' `� .s i % -,l:' - i ��C. ir') .�r /c.. I S ..� i.' R °� 1,.� 3�1'•L..: il'16 �i1''G.. Gi:� E-y1 i i �� �:J �,L � � � /_.�i
l f%l tiken. %) /!��' A-11,,:°A.: a/f 4 r iC J-1 0�4c a t_ �� X o s[i�a L.�u • /� s�� 0.r
re It m� 5c�' rvue f� I v? �e ge)x -
I, as owner or reported gent of o er agree to a conditions stated on this form.
l,�l.
SIGNA � TITLE DATE 1W ZCxrD '
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 p rformed in accordance with the above proposal and conditions.
Proposalapproved u
g
Inspector's Signature & Title DATE
COPIES: White (PCHD); Yellow (Town BI); Pink (applicant)
PC -RP 99ML