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00976
MAILING ADDRESS / vL U r, 1`e, -'- 1
APPLICANT )�— i%e " p, L N'1 G c� r1 /,rte c Ezo2_
Name & Relationship (i.e., owner, tenant, contractor)
DATE f ba1 // L- FACILITY TYPE PCHD COMPLAINT #
PROPOSED INSTALLER E. f-. hi PHONE # e'q/ -- /d"
ADDRESS / T A L—N y % 6 REGISTRATION /LICENSE # 11-26
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. /
Q- _ ,p Iri -r.-�- L'ys, ,- S `1 -c-oL -7i9�. IL. L.iiYh /3- /, o o y
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SIGNATURE TITLE �✓/�'- DATE
(owner),— -
I, the septic installer, agree to comply with the conditions of this permit for the septic system -repair
SIGNATURE TITLE (� wi`-t t- DATE
(installer) '
Proposal approved with the following conditions:
1. Procurement of any Town Permit, if applicable.
2. Submission 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 ft design and there is no guarantee to the duration at which the
completed SSTS repair will function.
DNo completed work is to be backfilled until authorization to do so has been obtained from the Department.
/ INTERNAL USE ONLY
Prop osal Appro 2111 Proposal Denied ❑
In ector's_Sr natu & Title e Date Exp ration Date
,
Repair proposal is in compliance with applicable codes Yes ❑ NoO�
COPIES: PCHD; Owner; Installer
PC -RP 99ML Rev. 2/07
py it
A JU
LANDSCAPE AND CONSTRUCTION
191 LAKE ELLIS ROAD
WINGDALE NEW YORK 12594
PHONE/FAX 845-832-3810
CELL # 845-222-1239
KEVIN O'DONELL
12 ORLEANS DRIVE
PATTERSON NY. 12563
DATE 01 /2 1 /10
Phone: 721-6147
SCOPE OF WORK: �-f-p 0 14 1- r-r, r,(, - r^-J-. t 't // wvj,
Ape0y -7
M
LANDSCAPE AND CONSTRUCTION
191 LAKE ELLIS ROAD
WINGDALE NEW YORK 12594
PHONE/FAX 845-832-3810
CELL 4 845-222-1239
KEVIN O'DONELL
12 ORLEANS DRIVE
PATTERSON NY. 12563
DATE 01/21/10
Phone : 721-6147
4?
- - - - - - - - - - - - ------- - - - - --
SCOPE --
-:-A " k - -,#
J
OF WORK-
7.7
00
vi
FEW
1/21/2010 Driving Directions from 191 Lake Ellis Rd...
2" ,U,,, JLIVIII I �., aLoy 0.3 mi
ELLIS RD.
Turn RIGHT onto D TAIL
3. CORNERS RD/ GTAIL CO R- _. 1.5 mi -- -- —
RD /CR -22. '
55. 4. Tur IGHT onto -55. 0. Mi
5. Turn L onto N 54 0.8 mi
cur Turn LEF , onto N, '2 S /NY-55 S.
6. Continu e'to follow NY -22 S. 11.8 mi
Turn LEFT �t}o HAVIL
7. HCLLOrCR~ �o7 m
..T a6�... /._
( 8 Turn RIGHT`onto� fMSTONE''RD t t�-
-
9 Turn RIGHT onto HAVILAND DR/CR- 0.7 mi f
67.
�► 103urn RIGHT onto SAGINAW RD. 0.1 mi
1
117urn SLIGHT LEFT onto JAVA RD. 0.2 mi
..........
a
12-Turn RIGHT to stay on JAVA RD. 0.1 mi
13 JAVA RD becomes MANCHESTER Q.1 mi
RD.
r'► 143urr RIGHT onto ORLEANS RD. 0.0 mi
15.12 ORLEANS RD is on the LEFT.
12 Orleans Rd Edit
Patterson; NY 12563 -1808
Total Travel Estimate: 33 minutes / 19.66 miles Fuel Cost: Calculate
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