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HomeMy WebLinkAbout1071DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 25.49 -1 -25 BOX 11 01071 AN IN r' IT L ' 01071 AN r. 0 ■ j AL Ale I ` 1:L wiwrmdri 01071 SITE LOCATION / OWNER'S NAME C MAILING ADDRESS r n !S7 PUTNAM COUNTY HEALTH DEPARTMENT . DIVISION OF ENVIRONMENTAL HEALTH SERVICES OFFICIAL USE ONLY TM# PHONE ,r JC ,:?7 ?- ,:;2� PERSON INTERVIEWED PCHD Complaint # Nanle,,U RelationsEip (i.e., owner, tenant, etc. DATE t� W E PROPOSED INSTALLER ADDRESS TYPE FACILITY Ras. • �: r REGISTRATION# ?2 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, o, repo d agent o o p.. er agree to the conditions stated on this form. g� SIGNATURE TITLE� DATE Proposal approved with Zekilowing 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 7rfb rme d in accordance with the above proposal and conditions. Proposal approved zit' Inspector's Signature & Title DATE COPIES: White (PCHD); Yellow (Town BI); Pink (applicant) PC -RP 99ML Street Town State Zip 'PERSON-IN CHARGE OR TNTF-IRVTF. .nary• 1lTLCD�(`T(1D. ��/1 9:;4//09 •rr.T _ 1 I I s V 1 loo / s � 5T W� III �I Ll- o-� r � t J �O0 i r.�IV -�j 0� s� ILI �o �s ,-ER1,j eta� LornBfaRD1 pup "Y 40 RQ V �l PUTNAM COUNTY HEALTH DEPARTMENT DIVISION OF ENVIRONMENTAL HEALTH SERVICES PROPOSAL FOR SEWAGE DISPOSAL SYSTEM REPAIR Internal -Uso Onl ❑ epair Permit issued in last 5 years VDelegated of in Watershed El ,Repair within Boyd's Comers, W. Branch or Croton Falls Res. ❑ Q Repair within 200 ft of a watercourse or DEC - mapped wetland ❑ Joint Review Q PROPOSAL FOR SEWAGE DISPOSAL SYSTEM REPAIR OFFICIAL USE ONLY iuc) Re PG t Rs t2S PN1 Cp SITE LOCATIOT OWNER'S NAN MAILING ADD] PUTNAM COUNTY HEALTH DEPARTMENT DMSION OF ENVIRONMENTAL HEALTH SERVICES �eD PHONE kys .Z?7k % PERSON INTERVIEWED go r✓r PCHD Complaint # am elatlonstup�t.e., owner, tenant, etc. DATE F5I oI¢% 6 TYPE FACILITY R�fS PROPOSED INSTALLERT�g�ut7��•tr�, PHONE,re279.5�cPQ� ADDRESS Proposal (include sketch locating all adjacent wells): REGISTRATION #33 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 reported agent ofjq�amer agree to the conditions stated on this form. i SIGNATURE TITLE DATE Proposal roved &ellgwing c 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 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. Proposalapproved Inspector's Signature & Title COPIES: White (PCID); Yellow (Town BO; Pink (applicant) PC -RP 99ML DATE LAKE SRORE I— — — — — — — — — — — — --- lot law — — — — — — — — — — — — — — T------ — — — — — — — — — — — - liam__ — — — — - - — — — — — z — - - - -- mm DEERFiElff DRIVE 7- NP. DEERFIELD DRIVE IS N) LAKE SRORE I— — — — — — — — — — — — --- lot law — — — — — — — — — — — — — — T------ — — — — — — — — — — — - liam__ — — — — - - — — — — — z — - - - -- mm DEERFiElff DRIVE 7- NP. DEERFIELD DRIVE August 2006 A T. 26.5 T. 6' 11.300 1. 20' 12. 22' 2.219 3. 23' 1 3. 24' 4.18% 4.19' !.5. 34' 4. 14'6 !, a a deck , Y A T. 26.5 T. 6' 11.300 1. 20' 12. 22' 2.219 3. 23' 1 3. 24' 4.18% 4.19' !.5. 34' 4. 14'6 °a ,.,tee 4 4 t3 2, �t large chambers i t i I t ' B Werner 14 Brandon Rd Patterson NY Tax map# 25.49 -1 -25 ,*-- concrete tank i 5 D box p Y4 ri€`� 7 c 1 � $ i�' {sTJ� -.,0 -pry '1 .t i.• OR 0/4LL SEPT /C SYSTEMS�s.� —sm w Jw9s- EXCAVATING CONTRACTORS _ 845- 279 -8809 wwwrsyodw //aop� /� com 4" �