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Home My WebLink About0755DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 24. -1 -41 BOX 8 00755 I% 6. ;Wit 1 f - r ,, 00755 W PUTNAM COUNTY HEALTH DEPARTMENT DIVISION OF ENVIRONMENTAL HEALTH SERVICES EATMENT Internal Use On n n Repair Permit issued in last 5 years Fl Repair within Boyd's Corners, W. Branch or Croton Falls Res. ❑ I Repair within 200 ft. of a watercourse or DEC - mapped wetland SITE LOCATION OWNER'S NAME MAILING ADDRESS D PERMIT # W U Not in Watershed V Delegated O Joint Review APPLICANT -- Name'& Rela' ship (i.e., owner, tenant, contractor) DATE i'I 03 FACILITY TYPE 1L&5t' (,c,,.A-1 SSA PCHD COMPLAINT # PROPOSED INSTALLER �nY /, lecheor PHONE # Ocis '- 222 -exti -2 ADDRESS REGISTRATION /LICENSE # 1033 Proposal (include a separate sketch locating the house, property lines, all adjacent wells.within 200 feet of repair and the location of existing and proposed system) NOTE: The Department may require submittal of proposal from licensed professional depending on the nature and extent of the repair, ._� 11� . st�.r �.r,k ,� �!,`,y�d•.�.c a {7' ,e(ut5 e-et 41%,, he. r 6�Ct'�� .1: e i' 0 be- >rtc' ":t 1y jIf-5, P� �✓ I, as owner,agree to the conditions st ed on this form Aeo,.v_ b• -C��- SIGNATURE TITLE DATE 4' (owner) I, the septic installer, agree to comply with the Unclitions of this.permit for the septic system repair SIGNATURE TITLE r! 5i /mil DATE (installer) Proposal approved with the following conditions: Procurement of any Town Permit, if applicable. 2. ubmission of as built repair sketch by the septic system installer within 30 days of the repair, in duplicate showing: >a. Owner's name, Site Street Name, Town and Tax Map number b. Location of installed components tied to two fixed points c. System description (e.g., 1250 gal. Concrete septic tank, etc.) d. Installers' name and phone number 3. System repair to be performed in accordance with the above proposal and conditions 4. The proposed SSTS repair is considered a best fit design and there is no guarantee to the duration at which the ompleted SSTS repair will function. 5. o completed work is to be backfilled until authorization to do so has been obtained from the Department. INTERNAL USE ONLY sal Approved Proposal Denied ❑ ctor's Signature & Title Date Expirat on Date r oroDosal is in compliance with applicable codes Yes _X No ❑ '• COPIES: PCHD; Owner; Installer PC -RP 99ML Rev. 2/07 � i V4/'L4 /'LVVd ly: IV FAA d45d(Uy'L'L'L AMAAX UAMtUN 0 SITE LOCATION PUTNAM COUNTY HEALTH DEPARTMENT DIVISION OF ENVIRONMENTAL HEALTH SERVICES PROPOSAL FOR SEWAGE TREATMENT SYSTEM REP) MIT # WRepair Permit issuad In last 5 years I.,,( Not in Watershed Repair wiihln Boyd'& Corners, W, Branch or Groton Falls Res. V Delegated Repair wlthin 200 tt_ of a watercourse or DEG�mapped wetland ❑ Joint Review OWNER'S NAME MAILING ADDRESS APPLICANT DATE Name Rol ship (i.e., owner, tenant, contractor] - FACILITY TYPE &5 rd4,P"'t 5SP PCHD COMPLAINT # PROPOSED INSTALLER V cw ke -Ao PHONE # 0 v) -- mV-Z ADDRESS J_,�Jr ag gj- ph%el� of .. REGISTRATION./LICENSE # 103 ro osal (include a separate sketch locating the house, property lines, all adjacent wells within 200 feet of repair and the location of existing and proposed syeWm) NOTE: The Department may require submittal of proposal from licensed professional depending an the nature and extent of the repair. 1002 /003 I, as owner,agree to the conditions s Won this form Q�L ��'-k A.. e-b 41.: (� .4� SIGNATURE TITLE DATE `Y �' iC (owner) I, the septic installer, agree to bompty with the ri tions of this. permit far the septic system repair• - SIGNATURE �'�" `— TITLE lAae` DATE Pf ..cinstalier) , Proweal approy1W with th � following cond ' ns• F'racurement of any Town Permit, H applicable. 2. ubmission, of as built repair sketch by the septic system installer within $0 days of the repair, In duplicate showing: a. Owner's name, Site Street Name, Tpwn and Tax Map number b. location of Installed components tied to two nixed points c. System description (e.g., 1250 gal. Concrete septic tank, etc.) d. installers' name and phone number 3. System repair to be performed in accordance with the above proposal and conditions 4. The proposed SSTS repair is considered a beat fit design and there is no guarantee to the duration at which the omplated SSTS repair All function. 5- o completed work is to be backfilled until authorl2ation to do so has been obtained tram the Department INTERNAL USE ONLY Approved Proposal Denied ❑ rfi. z� Gi & $ 0 s Signature & Title Date >= xpirat on Date 000sal is in comaliance with applicable codes Yes Ele- Nu' J COPIES: PCHID; Owner; Installer PC -RP 99M1 Rev. 2/07 (I' gs- iplel(OU-0 C +�. W x x - 3E p N N Tr- N CD LO co L i ¢ U- �t C2 OD O O N V f N O 7h/s mop was prepaed for the exclus/ve use of and Is certiAed only to. NICOLE SPRACU£ FIRST AMERIt:AN 717LE 1N57IRANCE COMPANY a, NEw Your but only for use In connection with their 77te Na 89881 -------------- No Lot 2 — 1 1 1 1 1 1 , k a A� g �. �S` 0K,3' Formerly BRANDON Now or formerly PLUNKETT ----------------------------------------------- Filed Mop No. 2700 rM. 24.-1-42.2 "LANDS OF PLUNKE Parcel 'A =29, 886 Sq.Ft. Parcel 'B "= 7, 900 Sq.Ft. rota/ Area = ,37, 786 Sq.Ft. Notes 1. COPYRIayr 1007' by BADLY B wA7SON, Surveying B Enginear/n¢ PC All Rights Reserved. Unouthw/zed duplicat/on is o violation of applicable lows 2. UnouthaNzed olterotian or addition to o document prepared by o licensed land suneya Is o violation of Secton 7209, SLb- Olvislon 2 of the New Yak State Education Low. * All caHM Baton are valid for this mop and copies thereof only !f sold mop or copies bear the embossed sea/ of the surveyear whose s/gnoture appears hereon. * if underground improvements; easements, or enaoxhments exist and are nelther vLsib /e dur/ng nano/ field survey operol/ons nor desenbed /n Instruments provided to these surveyors; they may not be straw" - this mop. S This property may be ofhreted by Instruments wh/dn hove not been provided to these surveyors Users of this mop should verify title with their altomey or o quolihivd title examiner. 6. Pact 14' is prgoerty described m the Putnam County aerie's Libor 1726 of deeds at page � Parcel T' is "Lands of Plunkett to be Annexed to .$rogue' as shown on that certain map entitled 'lot Line AdAlsiment prepared for Fronk A. Katherine M. Plunkett...,' wh/ah was filed In the Putnan County dark's ofece on Harvey 9. 2007 as Mop Na 270ak �Paed by BADLY do WATQAV son,. t Pc 0g77J'' of 2 rr ,8 P - TO BE ANNEXED TO SPRAGUE" (Portion of Lot 2 — Filed Map No. 2700) SURVEY OF PROPERTY PREPARED Fa? NICOLE SPRAGUE 5771/AT /N ME TOWN OF PA MERSON PUTNAM COUNTY NEW YORK SCALE 1 in. = 50 ft. SEPTEMBER 15, 2006 FEB 2 6 2007 Cold spcin& Now Yo ft 10516 (815) Z8S -9217 (977) 811 -IN3 Toll4m (816) 225-3312 (W) 286 -11Y8 (� (911) 829-1800 .: (914) 739 -9679 Hb hereby cart/6, that the survey shown hereon was completed by us on September 14 20016' that this mop was completed on February 24 2007 , and that this surrey has been prepared h occadance with the exlstIng Code of Pract/oe for Land SLrveys as adopted by fie New York State Association of Profess/ono/ Land Surve}or�t Ina P. C b b 2 M I N i ti a a 2 3 b Z 0