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PUTNAM COUNTY HEALTH DEPARTMENT t'
DIVISION OF ENVIRONMENTAL HEALTH SERVICES ® p
PROPOSAL FOR SEWAGE TREATMENT SYSTEM REPAIR�J
YES No/*` Internal Use Only PERMIT N'' ' .0 3 f y
❑ 0 Repair Permit Issued In last 5 years eDelegated of In Waters hed
❑ Repair within Boyd's Comers, W. Branch or Croton Fells Res. - TO_'kk
V ❑ Repair within 200 ft. of a watercourse or DEC - mapped wetland ❑ Joint Review
SITE LOCATION
OWNER'S NAME
MAILING ADDRESS
TM qa�5�' 73
PHONE #
W 9i7 - t'7S6 -16�
VL I/
APPLICANT J27&L
Name & Relationship (i.e., owner, tenant, contractor)
DATE 11g-/4 FACILITY TYPE PCHD COMPLAINT #
PROPOSED INSTALLER a- L;". PHONE # BSEj" 219 r4PG�
ADDRESSS6d tcL �� � 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 system)
NOTE: The Department may require submittal of proposal from licensed professional depending on the
nature and extent of the repair.
I, as owner,agree o the nditions stated on this form
X SIGNATURE TITLE DATE!
(owner)
I, the septic in aller, agree to co ply with the conditions of this permit for the septic system repair
SIGNATURE TITLE DATE
(Installer)
Pro oR sal approved with the following conditions:
1. Procurement of any Town Permit, if applicable.
2: Submission of as built repair sketch by the septic system Installer within 30 days of the repair, in duplicate showing:
a. Owner's name, Site Street Name, Town and Tax Map number
b. Location of Installed components tied to two fixed points
c. System description (e.g., 1250 gal. Concrete septic tank, etc.)
d. Installers' name and phone number
3. System repair to be performed in accordance with the above proposal and conditions
4. The proposed SSTS repair is considered a best fit design and there is no guarantee to the duration at which the
completed SSTS repair will function.
5. ' No completed work is to be backfilled until authorization to do so has been obtained from the Department.
IUIrEnLIA1 "OV f%L11 V
m cnI'm F.
Proposal Approved Proposal Denied ❑
�) :grz� I G,,:�gf
Inspector's Signature & Title Da Exp ration 15ate
,Repair proposal is in compliance with applicable codes Yes a/- No O
COPIES: PCHD; Owner; Installer
PC -RP 99ML Rev. 2/07
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L79-60(o
OWNER'S NAIL PHCNE
SITE LOCATION
MAILING ADDRESS., 1
� PFI INTERVIEWID ., PCHID Complaint #
Name & -Relat onship `ti.e, owner tenant, etc.)
DATE TYPE FACILITY
PROPOSED INSTALIR PHOt
Proposal ( include sketch ].orating all adjacent wells):
NOTE: Repair must be in same- locat on: and of- same . type. as original sewage disposal system.
Different location may :require submittal of proposal from licensed professional engineer or
registered architegt.
Inspector's'Signature & Title
Date
Proposal approved with the following conditions:
T .
J.- ocurement of any Tim Pezm t� if applicable.
2 Submission of as build repair sketch.iri duplicate showing:
a. Owner's name..
b. Site.Street Name► Town and Tax Map number.
c. Location: of installed ccmponents tied, to two fixed points (e.g.,house corners).
d. System desc#ption (e.q.,;1250 gal;: concrete` septic tank, three precast 6' diam. x 6' 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.
I, � as owner; or reported agent of` owner agree -to the above-. conditions.
SIGNATURE . � �, " .
TITLE DATE
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SITE
MAIL
PERS
DATE
PROP
Pro (include sketch locating all adjacent wells):
NOTE: Repair must be 'in same locatiorr and of same type as original, sewage disposal system.
Different location may require submittal of proposal from licensed professional engineer or
registered architect.
Date
roposal 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' diem. x 6' deep
drywells surrounded by one foot + gravel).
e. Installer's name and nm1ber.
3. System repair to be performed in accordance with the above proposal and conditions.
I,'as owner, or reported agent of owner agree to the above conditions.
SIGNhTURE r TITLE A �l DATE
.J�LiC.7: Wi a MV; ieUnw (Tam BU; Pirk (AppUcwV0
rM am
Date
roposal 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' diem. x 6' deep
drywells surrounded by one foot + gravel).
e. Installer's name and nm1ber.
3. System repair to be performed in accordance with the above proposal and conditions.
I,'as owner, or reported agent of owner agree to the above conditions.
SIGNhTURE r TITLE A �l DATE
.J�LiC.7: Wi a MV; ieUnw (Tam BU; Pirk (AppUcwV0
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61K, z7 - 600
ti
4 Sheet_ of
PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEATLH SERVICES
FIELD ACTIVITY REPORT
N A MF : Tel,
AT)T)RF7C4.1CJ
Street Town State Zip
PERSON IN CHARGE
Name and Title
TYPE OF FACILITY: S;.,c, (e )5�a,,A -'
FINDINGS: I + -f "r ateSke-, . A? pt 1;L,,, 0C,
Signature and Title
REPORT RF.0 TVFT) RV.
I acknowledge receipt of this report: SIGNATURE:
02/96
Rev.
Title:
f.
.10
5-06
pot
A -:s
C.,
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8't�- 7 71, 60
December 18, 1990
Department of Health
110 Old Rt. 6 Center
Carmel, New York 10512
Att: John Karell, Jr.
Public Health Director
Gentlemen:
As per your letter of December 10, 1990, concerning septic repairs
for:
3 Berwick Rd.
Patterson,N.Y.. (Putnam.ake)
enclosed please find the information you requested.,,
I trust that this information will be.satisfactory.
Very truly yours,
Jean Daniels
Owner of property
Enclosures: description of materials used.'an&diagram of
septic system location''.
cc: Chris Johnson, Dept. of Health
Joseph Garcia{ Installer:.
JohnCalbo, Building Inspector,Patterson
1
is t
PETER C. ALEXANDERSON
County Executive
Jean Daniels
PO Box 156, Kingsbridge Station:
Bronx
Dear Ms. Daniels:
An application for a sewage dis osa1 "system was;
County Health Department on 5 9/90
with the following cnndit�on
a)
b)
c)
d)
e)
Owner,'..s name .
Site Street Name, Town and Tax Map numbery
Location of installed components tied to._two'fixed. points
(e.g., house corners).
System description (e.g., 1250 gal-.'.concrete'-tank, three
precast 6' dia'm. x 6' deep .dryweIlLs'..surround,ed by..one.foot
+ gravel).
Installer's name and number.
You are responsible for submitting this informat;.ion';ao the Putnam County
Health Department within 30 days. Failure ..to-do so will make you liable
for penalties provided by law.
If you have any questions please feel free:;to.contact :;me
3
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JOSEPH GARCIA
43 ILIOH RD.
NEU FAIRFIELD,CT 06812
Customer's
Order No. _ _ DATE
1 �
SOLD TO �► a -�
ADDRESS
SALESMAN TERMS
ALL Claims and Returned Goods MUST Be Accompanied By This Bill
SIGNATURE
4.84411 PITTSBURGH BALEOBOOR CO.. PITTOBURON. PA. 10100
PETER C. ALEXANDERSON
County Executive
Jean Daniels
DEPARTMENT OF HEALTH
Division Of Environmental Health Services
110 Old Route Six Center, Carmel, New York 10512
(914) 225 -0310 .
PO Box 156, Kingsbridge Station
Bronx, NY 10463
Dear Ms. Daniels:
December 10, 1990
JOHN KARELL Jr., P.E., M.S.
Public Health Director
Re: Se tic Repair -As Built Sketch
3 Jerwick Road, Patterson
An application for a sewage disposal system was approved by the Putnam
County Health Department on - 5/9/90 The approval was granted
with the following condition.
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 tank, three
precast 6' diam. x 6' deep drywells surrounded by one foot
+ gravel).
e) Installer's name and number.
You are responsible for submitting this information to the Putnam County
Health Department: within 30 days. Failure to do so will make you liable
for penalties provided by law.
If you have any questions please feel free to contact me.
MB:CJ:jr
For the Public Health Director
t/Iry y4_puly yobWs
Johfi Karell Jr., P.E.
Public Health Director
By:
Chris Jo
Intermed
pson.
ate Clerk
555 W. 235TH STREET
RIVERDALE, NEW YORK 10463
TELEPHONE (212) 796 -7550
December 18, 1990
Department of Health
110 Old Rt. 6 Center
Carmel, New York 10512
Att: John Karell, Jr.
Public Health Director
Gentlemen:
As per your letter of December 10, 1990, concerning septic repairs
for:
3 Berwick Rd.
Patterson,N.Y. (Putnam Lake)
enclosed please find the information you requested.
I trust that this information will be satisfactory.
Very truly yours,
Jean Daniels
Owner of property
Enclosures: description of materials used and diagram of
septic system location
cc: Chris Johnson, Dept. of Health
Joseph Garcia, Installer
JohnCalbo, Building Inspector,Patterson
}
1.
PETER C. ALEXANDERSON `� JOHN KARELL Jr., P.E., M.S.
County Executive �Ii> �O� Public Health Director
DEPARTMENT OF --HEALTH
Division Of Environmental Health Services;° : '
110 Old Route Six Center, Carmel,' New e York. 10512
(914) 225 -0310
December 10.,-.1990
Jean Daniels
PO Box 156, Kingsbridge Station
4.
z`
Bronx, NY 10463 Re Se tic Re -anir As 'Built `Sketch
3 tterwnk Rpoad, {Patter on
Dear Ms. Daniels:
An application for a sewage d i s osal taystem was approve by3 #the Putnam
County Health Department on 519/90 The' :approval ,was `granted-"-
with the foling �nndition �y;`fi>
Submission of As -Built repair sketch in.duplTcateshowing..
a) Owner's name.
b) Site $'treet Name, Town and Tax'Map number'
c) Location of installed components'..,ti.ed to two fixed points_
(e.g., house corners). s ..
d) System description`(e.g., 1250 gal concrete tank.9 three
precast 6' dia-m. x 6' deep drywells s:urro,unded .b y.. one ;:foot
+ gravel).
e) Installer's name and number.
You are responsible for submitting this information'\`:t'o`the Putnam County
Health Department within 30 days. Failure to.- Ao:- so`�will make you liable
for penalties provided by law.
If you have any questions please feel fr.ee_. to con't'act..me.
(J> v 7F /cup[ /1yc �� AL . r , / /�; �.l „7 ' / 3
oz
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JOSEPH GARCIA
43 ILIOH RD.
NEW FAIRFIELOXT 96012
Customer'sii,
Order No. � — DATE
SOLD TO
ADDRESS �p� l
SALESMAN / TERAAS '
ALL Claims and Returned Goods MUST Be Accompanied By This Bill
SIGNATURE��
4.110411 PITTBBUROH BALBBBOOK CO.. PITTBBUROH. PA. 90100
ASSESSMaT PURPOSES ONLY'
TO BE USED FOR CONVEYANCES
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IES W. SEWALL COMPANY
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