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HomeMy WebLinkAbout1070DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 25.49 -1 -24 BOX 11 1 ro 11 161ma l :4 T A _ , all 01070 PUTNAM COUNTY HEALTH DEPARTMENT DIVISION OF ENVIRONMENTAL HEALTH SERVICES 'ES NO Internal Use Only ❑ /I�tepair Permit issued in last 5 years El ;/*Repair � Repair within Boyd's Comers, W. Branch or Croton Falls Res. ❑ within 200 ft. of a watercourse or DEC - mapped WpUani SITE LOCATION OWNER'S NAME MAILING ADDRESS _ v ❑ Not in Watershed Delegated ❑ Joint Review TM #OD' ~ �— I_Q(t APPLICANT V exit be l ?C) be447S Name & Relationship (i.e., owner, tenant, contractor) DATE ?j In 6, FACILITY TYPE VPS. PCHD COMPLAINT # PROPOSED INSTALLER 1 tj ' PHONE # Z q —g- rO 71 1;-51*11 . V ADDRESS V, � 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. e I, as owner, or reported' i e- &+ 1F Liz Y el- r�, conditions stated on this form TITLE 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 conditions. Proposal Approved Proposal Denied if, 5 8 od Inspector's Signa ure & Title Dat COPIES: White (PCHD); Yellow (Town BI); Pink (Installer), Orange (Applicant) PC -RP 99ML Rev. 8/05 cow4ty, k. March, 2006 i M T. n/a 1. 32' -2. 36' 3. 42' R- 027- 06 { i owell Roberts 10 Brandon Rd . Patterson Tax map# 25.49 -1 -24 T. 8' 1. 15'4 2. 22'9 3. 30' oi4LL SEPT/C SrsrsMSon.. — M nwss — EXCAYAT�N�. CONTRACTORS 84v- 279 -8809 r►a�►w.trodo / / =opgc com I acknowledge.receipt, °ofthis report: :SIGNATURE: 02196 Title,..:' ate. ae -' PUTNAM COUNTY ''DIVISION-OF W Y� -- DEPARTMENT EIy VIRONivIENTAL FIELD ACTIVITY ;OF, i1kATLri REPORT :: FIEALTH aEf2YY(,'E5 Sheet_ of, NAMF; Yk'2b i- 45' _V j . AnT)RRRR: tO JB ra- tCOV` IC.4�axd . ;..;Street .' Town = > -State Zip 'PERS:ON IN CHARGE, P*7 C)R TNTFRVTFWFT). T)' te. Nam_ a and Title - , TYPE OF FACILITY::. FINDINGS• /` /S`��0 i� iyisoe-1-iov► VVL t. &e i�Gi.E i VI A ~' �vC.e�'t it ©V1 CL._ �y'� in, i 1.� GL�, f.. , : I Ile ,. TNJqPFC OR Signature,and Title I acknowledge.receipt, °ofthis report: :SIGNATURE: 02196 Title,..:' Olen M. EXCAVATING CONTRATORS N-Rz&:; -Brewster, -N-Y-10509- (8#5)r299- 88fl9...__.._......._._..._ vie. I I wowe/d� wif WWII