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Home My WebLink About1028DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 25.47 -2 -29 BOX 11 01028 ro ii r ., me �1-1 T r F :` L A r L 01028 e a- PUTNAM COUNTY HEALTH DEPARTMENT . DIVISION OF ENVIRONMENTAL HEALTH SERVICES OFFICIAL USE ONLY • !► SITE LOCATION pc)_�Po_/71TM# of bLo —4cA OWNER'S NAME �. 7 • C-CC h'1 �i p PHONE �/� o� ? sC— ( �j �, MAILING ADDRESS JR 4 Q Ad &, PERSON INTERVIEWED PCHD Complaint # ---Name & Relationship i.e., owner, tenant, etc. DATE 10- l3 -0 TYPE FACILITY VM64 er /40-1 PROPOSED INSTALLER c%' MLOVYk Y-SOV PHONE g`tv�^ �0 2—I1 —O ?r7 ADDRESS /Z-8 s9c a 2 R PO M#HzWo c 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 engineer or registered architect. I; 'as owner, 'or re po agent of owner agree to the conditions stated on this form. SIGNATURE TITLE 0WAUI� DATE 0 // 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 be erformed in accordance with the above proposal and conditions. Proposal approved I _7 .1 A�_ Inspector's Signature & Title DATE COPIES: White (PCHD); Yellow (Town BI); Pink (applicant) PC -RP 99ML SHERLITA AMLER,- MD,- MS,- FAAP.. - -. - - Commissioner of Health LORETTA MOLINARI, RN, MSN Associate Commissioner of Health October 17, 2005 Mr. Joe Saccomanno 8 Reading Road Patterson, NY 12563 Dear Mr. Saccomanno: 0 DEPARTMENT OF HEALTH 1 Geneva Road, Brewster, New York 10509 -- ROBERT 1. BONDI County Executive Re: Repair — Incomplete — R- 292 -05 8 Reading Road (T) Patterson, T.M. 25.47 -2 -29 Review of plans and other supporting documents submitted at this time relative to the above regarded repair has been completed. The following comment is offered: • It appears the proposed repair will further encroach upon the owner's well. The repair must be installed in the same location as the existing system or, if an alternate location is considered, a licensed engineer or registered architect must submit a proposed plan to this .Department for review. Upol receipt- of -a - subrnission -to- reflect: the- above comment; -this repair • application will- be • considered furthered. If you have any further question, please contact me at (845) 278 -6130 ext. 2261. Sincerely, Gene D. Reed Sr. Environmental Engineering Aide GDR: cw cc: Jablonski & Son . 'Environmental Health (845) 278 -6130 Fax (845) 278 -7921 Nursing Services (845) 278 -6558 Fax (845) 278 -6026 WIC (845) 278 -6678 Nursing Home Care Fax (845) 278 -6085 Early Intervention/Preschool (845) 278 -6014 Fax (845) 278 -6648 DIVISION OF, ENVIRONMENTAL HEALTH SERVICES PROPOSAL FOR SEWAGE DISPOSAL SYSTEM REPAIR YES NO Internal Use Only V epair Permit issued in last 5 years of In Watershed ❑ �epair within Boyd's Comers, W. Branch or Croton Falls Res. Zelegated Repair within 200 ft. of a watercourse or DEC - mapped wetland ❑ Joint Review SITE LOCATION i1� TM# OWNER'S NAME �r--?�&Ju ' �=-� ` %'>'? �i CJ PHONE �/� of 7 9 - Q!5 fir, � MAILING ADDRES tj 6.J ':,Cr' St],L/ /I PERSON INTERVIEWED PCHD Complaint # ame & Relationship- i.e., owner, tenant, etc. DATE_ 10- l3 -0 TYPE FACILITY 9'r Z yr PROPOSED INSTALLER O— WOVSk'_ &' - -SOai PHONE ADDRESS 12-0 SCC Q 2 APO M dt fo c REGISTRATION# PG 6-b P=osAl (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. I, as owner, or repo agent of owner agree to the conditions stated on this form. SIGNATURE TITLE �� DATE Q // 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 be performed in accordance with the above proposal and conditions. Proposal approved P- --fJ'r Inspector's Signature & Title DATE COPIES: White (PCHD); Yellow (Town BI); Pink (applicant) PC -RP 99ML I •e? -T f - C, D I . (ttz 7 L ffAl , e r-4 I fl 6 2- (c 0 BMW A