Loading...
HomeMy WebLinkAbout1376DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 25.79 -1 -61 BOX 13 1 ru 11 rr x '_ • �^ �I VI q.6% T J '.L I � ML ti 01376 • � is PQM Complaint # Name & Relationship (i.e, owner,tenant, etc.) REGISTRATION # 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. it rd Proposal approved with the following conditions: Date 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 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 arm: Mite (PAD); Yellow (Tam HI); Pink (Applicant) DATE Robert J. Bondi County Executive Permit # W-5 c2 0/ *S — Q � ' Cris Dellaripa t Septic Repair Inspector Edward A. Barnett Watershed Information Coordinator • PUTNAM COUNTY SEPTIC REPAIR PROGRAM 100 Rte. 312 Bldg. #4 Brewster, NY 10509 PCDOH Attn: Michael Budzinski 1 Geneva Rd. Brewster, NY 10509 Michele Palermo Office Manager Date: I Aiv 2 L- n Dear Mr. Budzinski; We wish to report that the following job: Name (,._ Lj y ('D Address 111 _d vZ /'a f1 Tax ID# 9S* • 79 4 has been completed as per the approved drawings. As -Built Attached: Yes No V/ Sign ed CC: Dan Shedlo, P.E. Telephone: (845) 278 -8313 Fax: (845) 278-2318 DIVISION OF ENVIRONMENTAL HEALTH SERVICES PROPOSAL FOR SEWAGE TREATMENT SYSTEM REPAIR 'ES N Internal Use Only PERMIT # � A �r- ©� ❑ Repair Permit issued in last 5 years ❑ Not in Watershed ❑ ❑ Repair within Boyd's Corners, W. Branch or Croton Falls Res. ❑ Delegated ❑ ❑ Repair within 200 ft. of a watercourse or DEC - mapped wetland ❑ Joint Review SITE LOCATION _-.2/1p %�W ,, � � TOW N Pa, TM # ��1 —/—.// OWNER'S NAME t �n a veu°A PHONE # MAILING ADDRESS APPLICANT P Name & Relationship (i.e., owner, tenant, contractor) DATE // FACILITY TYPE PCHD COMPLAINT # PROPOSED INSTALLER PHONE # ADDRESS 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 to the conditions stated on this form SIGNATURE 61-1 /-� TITLE DATE (owner) I, the septic installer, agree to comply with the conditions of this. permit for the septic system repair ,/ SIGNATURE TITLE � DATE /Q (installer) Proposal 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. INTERNAL USE ONLY Pro osal Approved Proposal Denied ❑ I (map o Insi ector's Sign riscom T Date Expiration Date Re air proposal iance with Ja lica odes Yes No O COPIES: PCHD; Owner; Installer PC -RP 99ML Rev. 2/07 C 4- PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL HEATLII SERVICES FIELD ACTIVITY REPORT ADDRESS: I 10 7a9, &&r.&. /ki ' v, Street . Town State Zip PERSON IN CHARGE i9hp/:5 "b, nt) TNT1r"Q1)1%7rrxxMn. P TP Name and Title TYPE OF FACILITY : FINDINGS: #V V14-A. a D 2 014. ------------- Signature and Title R FPQR TRFC F.TVF-T) 'BY: I acknowledge receipt of this report: SIGNATURE: 02/96 Title: Tw WE 11. toc$' ;J> '° ,'.•'vim a7 p'--a- MAN PC -PQ Ift e q sm I Ot IMP�.�, ` a ,'h�i'- .5•T,� {„'��,. 41�' ,'fey` t +?,t�Y ' Mks « i•x 3 " 9— _"�l�qw� MOO titrr ti a I i i J t � mr•. —.. +E$ ,fir AMMER s""• � �y t <+ �'s mow lct - - 'm•Z .,fie „. ' Nab � � -� cis 1r "�', �! � �,,, y�t.�u� �,� ��"o r� �" ,'.� - •. �� �2 ��. ;y r Y 2.• E � C $`a sS 1, A NO ENPIOTM- �l d sue' l 4 W ry, Toy y 5 0. /"a aY' Q. q r W _ '. 'r l IQ t .'arm .� }�,'I� t � � �° �• �g :x. '"�.'�'- r3��k..' "�.'`a` �! �yy`$'�V�' � '` a � � Y 3 # �a rf 4i14 It a �r� " fw j •- t4 1 Y( f 3 f i y AN r _ R. � •� '��•�LM. `• ��,�`�� ia� 4b# 71^`GF'f�� �J �6''/ fig* t�. A M � ���a.. :I rJ fi `'fJ r �j �4.M6 ` ,y' �•, i .MKS, � , Y,w :rp,� 7(;,�.�F! +" 7 i W1 i �-TM+ § * } Y .........b a "r ZZ JS) a } r DII t� d � . f � t �?y.r: Y.S I� • .y. Pll� i 1& i r`'�r `��zriaexe lot, 'v { � �F' Spa `t w r �? , Y H, E yl h e Yi +r4 � t 1 Y � ✓ t' 2: F 0l i l eat r tx 1. E �{ t• 'r 1 {� NyOn F ' F w �' of a x 7rt , . ts. �•� ►� ,�;, �,G; - y � n � •l! '+. y. i b.k� r f a is r' t§ ,� I 3 Y i 3 M1,�• 1ljj'. c5 VF{,LS 1,� r'• �s19Jq`' �x E✓•{ ! x: •G z 7-�, ry� 1 � � r{ r �,'• ski t i :•i ! j riw • 'i -,r l al I . � 4 4a�5 '?:�, � i FA x�, a 1ljj'. c5 VF{,LS 1,� r'• �s19Jq`' �x E✓•{ ! x: •G z 7-�, ry� 1 � � r{ r �,'• ski t i :•i ! j riw ®r ol gO N1, Wr, Rl� -z R- A VIA rXjG 71.1 -,17 % RNMOM-, "M -k Ali Vk 7� 1 AM 'MIS -e- 4, 4-4 SV,7171 �A gg, 50 r