Loading...
HomeMy WebLinkAbout1055DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 25.48 -2 -19 BOX 11 01055 rim IN . % 1 I ` :I I r, ; ` -� $' ` T, o _ 01055 PUTNAM COUNTY HEALTH DEPARTMENT DIVISION OF ENVIRONMENTAL HEALTH SERVICES SITE LOCATION LAAJRE.r�Ge a 47"TE TM# a.5-- �1,�' - OWNER'S NAME �,9�lb_.vv a 6a j PHONE 3 - MAILING * ADDRESS SW C /4-5 i9,1 ov 4 PERSON INTERVIEWED Ae, /ylr.ciOr - PCHD Complaint # a ationp i.ame tenant, etc. DATE 7­13 - Zee, o TYPE FACILITY S S PROPOSED.INSTALLER AWQ&c ,� PHONE S yS- MI6 2.- o So y .ADDRESS 31 &I. a&,.) L to REGISTRATION# Proposal Oinclude sketch locating all adjacent wells)! NOTE: Repair must be in "same location and of same type as ori ginal sewage disposal system .Different location may require submittal of proposal from licensed professional engineer or registered architect. 44.1s f oricported-agent °of owner-agree--to the - conditions stated - an-this %ran: -_ °-' _ ............._....._ SIGNA TITLE/' 2 le, DATE O " Z�Z©o C5 Proposal approved with the following conditions: 1. Procurement of any Town permit, if applicable. I 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 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 99ML DATIC li Fax:914- 773 -0343 Jan 29 2007 11:23 P.01 0tY DU'gQr�� New York City am �; D►epartment_.of__ 0ap Environmental Protection SUBSURFACE SEWAGE TREATMENT SYSTEM REPAIR DETERMINATION Pursuant to the authority granted wader: Article 11 of the New Xork State Public Health Law; Rules and Regulations For The Protection From Contamination, Degradation and Pollution Of The New 'Y'ork City Water Supply and Its Sources, 15 RCNY Section 18 -38 (or Chapter 18); and 10 N-XCRR Apper di x 75 -A Wastewater Treatment Standards - Individual Household Systems; Putnam County Septic Repair Program Plan — March 2005. DEP Project# T gt4 _ PCIEID Repair# (o ~ 6) -7 Site Location: LQ4� ✓Prd+C�- �✓. ? x.lvi. #cs� "''" 1 Reason for Joint Review: Drainage Basin 200' of WC/Wetland Repeat Repair in 5 Yrs. Name of Owner: 11A A e W 4u1 ..? ;) A-mrtr Owner's Address: Installer: 14 0 ? r 4) Mr.. General Description of Sewage System. Repair: Pdk'.4 "r L Pk (Jul �e & (_T_r6 7'E<Z/" t=,, Dates of Site Inspections and Soils Tests: Approved *Incomple Delegated "Denied *Required: Soils Tests Repair Sketch WC/Wetlands Wells Other "Reason Dete made by: /07 Engineering Division Date Permit # WS — o a- 6 -709. Robert J. Bondi �:;: Cris Dellaripa County Executive Septic Repair Inspector S Edward A. Barnett Michele Palermo Watershed Information Coordinator Office Iytan�er . - PUTNAM COUNTY SEPTIC REPAIR PROGRAM 100 Rte. 312 Bldg. #4 Brewster, NY 10509 Date: PCDOH Attn: Michael Budzinski 1 Geneva Rd. Brewster, NY 10509 Dear Mr. Budzinski; We wish to report. that the following job: Name &— e- cs Address C-e— _10 r:- , Q'y`� 4%, Ke_ ' Tax ID #,;_Q has been completed as per the approved drawings. As -Built Attached: Yes Lam No Signed CC: Dan Shedlo, P.E. ne,�a Telephone: (845) 278 -8313 Fax: (845) 278 -2318 Oe ycr. I ve, GraJ e� oul cv-(s �y.� 34 PUTNAM COUNTY HEALTH DEPARTMENT DIVISION OF ENVIRONMENTAL HEALTH SERVICES PROPOSAL FOR SEWAGE DISPOSAL SYSTEM REPAIR _ YES NO - Internal Use Only- El Repair Permit issued in last 5 years ❑ Not in Watershed ❑ ;/A epair within Boyd's Comers, W. Branch or Croton Falls Res. /l ❑ Delegated %a vr u o pp I 1 /� 4W GGG000 Repair within 200 ft. of a watercourse r DEC-mapped wetland Joint Review SITE LOCATION �, ��✓� !�, �� TM # OWNER'S NAME Mpg �,/�T � PHONE # V- MAILING ADDRESS s �•ti L ` �/� w 2L� t L �g �W J 7E'r rJ,/ / t?f p APPLICANT C S Name & FTelationship (i.e., owner, tenant, contractor) DATE FACILITY TYPE PCHD COMPLAINT # PROPOSED INSTALLER /J Tp PHONE # ADDRESS REGISTRATION /LICENSE # 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. trenches) NOTE: Repair must be in same location and of same type as original sewage disposal system. Different location and proposed pump systems will require submittal of proposal from licensed professional engineer or registered architect. I, as owner, or reported agent of owner agree to the conditions stated on this form SIGNATURE ' TITLE Pc, r. DATE / //6 U 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 d. System description (e.g., 1250 gal. Concrete septic tank, etc.) e. Installers' name and phone number 3. System repair to be performed in accordance•with the above proposal and condit' ns. Proposal Approved Proposal Denied �. , /fir`. , A Inspector's Signature. & Title Date COPIES: White (PCHD); Yellow (Town BI); Pink (Installer), Orange (Applicant) PC -RP 99ML Rev. 8/05