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HomeMy WebLinkAbout1323DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 25.73 -1 -35 BOX 12 1 ru I a !; i 4 ', rm ' ` OiT ly.. ,. 6 4' f ' , .1 No 01323 ` 01323 PUTNAM COUNTY HEALTH DEPARTMENT DIVISION OF ENVIRONMENTAL HEALTH SERVICES 225 -0310 .PROPOSAL-.. FOR--SEWAGE DISPOSAL SYSTEM REPAIR jo OWNER'S NAME A /_ j- rr� C�, �Y r► Gi L o t--i c! r G t 'c . s.- �' PHONE SITE LOCATION 13t. rc,) 4' c. h R o a cA i Po fi/i c, an i-- a f( e- . /` l-t Msm TAM$ a ` MAILING ADDRESS :Z l3r- i c R\ P o a,A S s`"C V 9 PERSON INTERVIEWED Pam Complaint # 0- QC- Name & Relationship (i.e, owner,tenant, etc.) DATE TYPE FACILITY !? ,` of e 1-1 G e- PROPOSED INSTALLER y ck r o c- c- � tf i �� . PHONE a `% 8- cf 3 9(4- 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. -? L/ f.;61 t � � r �- � a ., �'� � � �c_c.c C L a ex l�n r'►�vv{. ►� /'L'G'�rL•�C ors �! i e�c�a�S Cis L( �2 �rr,G,i�� T"o r 1., o uf- o F 7- A e. .€ x , S t/,, cgs s f tv► . Proposal roved Proposal Disappi 's SkWhature & Ti with the following conditions: 1. Procurement of any Town permit, if appl 2. Submission of as built repair sketch in a. Owner's name. b. Site Street Name, Town and Tax Map n c. Location of installed components tie d. System description (e.g., 1250 gal. drywells surrounded by one foot + e. Installer's name and number. 3. System repair to be performed in ac rd to showing: uuva . to two fixed points ncrete septic tank, el). //Date (e.g.,house corners). three precast 6' diem. x 6' deep with the above proposal and conditions. I, as owner, or reported agent of owjfer agree to the above conditions. SIGNATURE S,Q,�- 4V L, 1-4- 4�1SI TITLE _ PW: Wiite (PCED); YeUcw (Z,, ED; Pink (Appliamt) 7w U PUTNAM COUNTY HEALTH DEPART DIVISION OF ENVIRONMENTAL HEALTH SktVICES 225 -0310 ;L, ® PROPOSAL. FOR SEWAGE DISPOSAL SYSTEM REPAIR �9L �v� �- L �r' OWNER'S NAM r1l (3 uLC r� P�c�vE i SITE LOCATION MILING ADDRESS :Z Oft b W i c h rJ Vie ev s fz�L- PERSON INTERVIEWED PCHD C®nplaint # Name & Relationship (i.e,, owner, etc.) DATE TYPE FACILITY PROPOSED INSTALLER c PHONE Wee' 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. Proposal approved Z �Z/ // Dat�� Proposal approved with the following condition$°. 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 Imo, Town and Tax Map number. c. Location of installed canponents tied to two fixed points (e.g. ,house corners). d. System description (e.g., 1250 gal. concrete septic tank, three precast 6° diam. x 6.1 deep drywells surrounded by one foot ¢ gravel). - e. Installer's name and number. 3. System repair ;to be performed in accordance with the above proposal and conditions. L as owner, or reported agent of owner agree to the above conditions. SIGNATURE TITLE DATE DPI 1: %Ate (P3HD) S Yelljw CRi�n ED; Pink (kz2 iQmt -) 0. PUR" C OUM HEALTH MWARDONT DIVISION OF ENVIRONMENIAL HEALTH SERVICES 225-0310 —-PROPOSAL FOR SMAGE -DISPOSAL 7 SY64IM-REPAIR OWMOs mm AtFv-co( Te. Ck 4 (�A L- 0 rJ PHONE SITE UXATION J& r4kj"c_ Roa -A pt)-f-'ric, "n L-CkRt MAILING ADDRESS . An JMADMESS' J& V LJ 'e; 1 R O a A PERSON :INTERVIEWED., PCH!) Caq3laint, # � 0'r 70- Iq Nam & Relationship (i.e, ownerotenant,, etc.) DATE TYPE FACILITY t? Ot -e- m C. e- moposm i%TAuM 1k. PHONE Proposal (include. sketch locating all adjacent wells): NOTE: Repa it must` . t "be in same, location and of sane •-ttyp as original sewage (#sposal systemii p Different location. may require'submittal of proposal from. licensed professional engineer or V, .registered architect. C, S Gv ca c 1"S r S C S 4r -+e 2 9 Proposal appr 1V *rkgz' Proposal Disapproved 1s/,Vg_nature & Title. i9ft&ctor. Date ~Proposal - approv6d,,'with the followincr conditions.- 1.' Procurement of any, Town permit, if applicable. .-2. Submission ..'-6ffAs built repair sketch in duplicate showing: A. Own eirl s, nafile b. Site Stree Naine Town and Tax Map number. ­ Iodation. of, installed caq=ents tied/to two fixed points (e.g.,house corners). d. System&s6ription (e.g.,, .1250 gal.,6oncrete septic tank, three precast 61 diem. x 61 deep dorywells surrounded by one foot + gravel). e. Instal ier Os .. name and number. 3. System repiair"".to be performed in acc6rdance with the above proposal and conditions. 1k I, as am . er, for reported agent of owner agree to the above conditions. IGNATURE !' <r t TITLE DATE US: *dte� (P(Jb):1-'Yd1cw (Mm HI); Pink (AniiMnt) 0,��'�ti W d* St'i0' 41" L i PIN � 22.31 zaa9 2ZZ8 aa��s c Ao'. ►' aa31' y� sac3z 1 0. h Z2�'1 'aa3sl � � Owru. 6TOey F>es�*ME / ZZ27 g f ,I gE:aw o� � 01 / PB.�i�.fagp �o� LOT- U®s. 2zzs o zz m � "Tf4100, MAP. <=F DUTK*M LAS''? T-c� \.C-J kj ©F' D�-rr�e S ©ter P UTr J 4 NA Y. 5C-4IL �. I" _ �p " MSG I--t 3�, i 9 S4 C�(�TIGIED �� PvmL.IC 6CRUITV.d-d*CLi9 RDIZI.T �+B4T?AaJf ,IAJC. F°Ota YN6- IDCsL�GY �'+N'�IIPI c ncl�nolu, IIJDIG�TE� NE7FOl -i 5161JIN 'w-r 1141�i sv¢�y WA9 PeEA4eED IL! AcjCo ZDA>JCE ILM 'IUE EXISTILJG CODE Cd PeAMCF- CtV- LAI.ID A.oOPTED B4-ME LEL1 11W. STa,7E. AoV7cCAATIC" c)' PeCCE6A Ok AL L AJD St i. SAID cksp- PCAM'o1'r ,E, A 2LgJ OWL`( -9D0lUE. PEZCi J me >ty w 711.E 45L..12VE`( IS FOEPAP.ED AWD OU 1115 eg-4 6L.F 10114E TTTLE. COAAPALI`l A"D LP-) 1D 06 tklES YfUT W LFS7ED +4EeiEp41. GEg77G1C1:f100.1rf AeE A-0 -10 ADnrncIL"L tk4,5 rl%-MC /JS CP- 6LSSEOX)E"r ar1AEZr7. •,111 014-5 "C w, o 4cF. .Jc*,, uo Pik 7-s.--z-#'4 L414-=m )ZIZEO ALIF -OATMJ M ACDMOL1 'tp -W%6 MAP 107 A Q10L�W CC- E. f C)LJ'*` L AkJ. LAJDE.0300LOJD SiRJCfUCE_S, IC ALP1 Ur '�edOkJQ. ALL c- OMCKAxrC ,? WEP_EOJ d4,E VA.LIP A7E TW Vi AMP A,AJC> COPIE,17 lVEPECr OWL-4 IC hAID MAP OV- CGPiE� BEAZ 7U6 MAPOE60AED ,6J CC-TVE �I�VE`(OeZ YJI Io,�F- -5A v1.L4RJ2>E. APREAZols 1lE.e&-i:O.J . KI E. AAA.II`l ':sTIZEF� ' 6MICATICH - ADDITION - (RESIDENTIAL ONLY) Name: �- • - _ . • . iShoneK — 7 - % Year of Or.i g i na 1 Street i' ' �r i`7 �t TMs ' Mailing Address � — Town _ • � -- c .'r i' Description of Addition _ Construction PCHD Permit - ✓ /-:Y Number of existing bedrooms t- ` Proposed number of bedrooms y c— •' Aj Square Footage of existing house 81 Square Footage of Proposed Addition -5-0 % increase in floor area ( A divided by 8) X 100 = Please submit this form and the following to PUTNAM COUNTY HEALTH DEPARTMENT, 4 GENEVA ROAD, BREWSTER, NY 10509, Phone 278 -6130 with the following information. IF THE PROPOSED ADDITION IS GREATER THAN 15% CERTIFIED Q4UXgR MONEY O 1. CHECK for $100,00 2. Sketch of .existing floor plans (all living area including basement, if any` Non - professional drawing 3. Sketch of proposed floor plan. Non professional drawing 4. Copy of survey showing well and septic location, to the best of your knowledge. Include date of installation if known. Any questions please contact William Hedges or Robert Morris. IF •)-:E ACOITICN WILL RESULT IN AN ADDITIONAL BECPCCM 7H.AN CE?T I F i c -D QjCK OR MCNc E_Y CPC F-:; 1. CHECK for $100.00 2. "---etch of existing floor plans (all living area including basement, if any` Non- professional. drawing .3~ ..Sketch -of -proposed floor p am _ . _ _.. _.... . Non professional drawing 4. for the Sewage Disposal System prepared by a Professional Engineer meeting present code requirements, may be required. AFFICF k�nE Cywtm !,:; : -J.icy .:�rditions Z. Ar,Nr„V @d by: TI 1LE Gate: cc: B: (T) addition r' B E P I L: P D p L 9 IIJP N, 0 23 :35 . ......... . . :3h 2:3 14 23 -First floor new famly t'C'Cjrfl old bed rooro a In Cl Cl In 2 -2, ................................ ........ Im um MMMIMHRMMRMMMMM old kitchen s. 7-A 5.7 x, dining j i i t, ClOrli bat hr oom ms IN 21 12 i v ¢=339.e2• o =a =tio' -�I• � � L� V �(/ •ow e �ti�ti yx, '2230 _toe zz%3 L26Z ` A Lzzs 4 y,p -loti ^9 2224 1 / \ oub BE��.JIG�o� ,bo ^o PQ.6f- 1t1Q.6P FOe.,, AL.FiZED C3UC G I E.2 I, J Q. LOe.I � UGG I E2 I 'LOT o.s SNO�..1►.1 cu "TL- iocp ., AP. <?F PuTP*M t:s�li.l�'.:-'�MA�1+w¢6Z-14 -FIND TC� \,L P UTNJ ANA GO, � ki . Y. 5C�.LE. 1".- 3O,. MA,!`GW 30, 19 a4 GaQ.TIFIEaD To Pwa% -IC 64R .ry =C.R f FOOT A.QfTQ/assT ,IwjC. FOQ TML, xolc:v i '3•jl{OI cEZRCIGATci.* µJDICA'T� JFocnl 51T.I.ACH -T"r 'fµ14 6uO\.EY WAfi PZE -FAVCn J I AGCOZDA YC W,M -INE EXISTIL. G. CODE tt' FeAGTIGE LCZ LA"D �.�.JD� VE ADOPTED W-'ME L*.kJ 10046T$1E A ACCAAiMW cP PeccEbOAOLJAL LA► IDSLJDJGI GeS.4AIDCE=LIC.A.TILM1 4NALL QL1.1 awLV -Tb -w- PEQ<,GYJ Poe k470A 211E �y f5 POEP ZED AUD o1J NI's BEWILF l0-NE TITLE CAAA.PALN A lD LFXJD( 1.16 u4t1YILincs -i LKoED "EOEO . 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