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HomeMy WebLinkAbout1324DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 25.73 -136 BOX 12 Elm ' I � '�', 1 r 11 , 1 .. Y I l 6L , g, f .L i .L �r jr I W. i h r I LOUIS I ON 01324 V 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 i I In l � ��� t,//ve- - 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 I .�, tj 3 7A� El ,SOO �1fF't,u -�bu\4 on 1-7 CAS i � yVl6f 3F t I i a� 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 o j�►4.ra Posc�'1 5� cam.-- �-� ��b�� 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., 0 Az� 1-7 q, /a, 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 IA-e- 9 r 4 O y 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 J0. I ►• a 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 �� � . IES W. SEWALL COMPANY TER• STREET; OLD TOWN,' (MAINE .... ..... ir. .. r.. .tr1 fly' •. a iV.4�Ll •� 1 r •\ I 432 '. Inc Q Li- I �/ c le y . . FR ........ 41 Xo AC> 45, evIr 13 Poo R Fpo"roy; Z3 r f r _ S�,�' eL