HomeMy WebLinkAbout1623DOCUMENT CONVERSION SERVICES PROVIDED BY
IMAGING & MICROFILM ACCESS, INC.
www.scanyourdocs.com
631- 589 -8100
34.13 -1 -14
BOX 15
01623
NON
NO
,,
_,
.
J
IN .
i �
NO ; :
, L,
�
ON
T '
ON
L
rr
I
r
1
j
NO
'
'
01623
SITE LOCATION
OWNER'S NAME _
MAILING ADDRESS
tJ 6 V-ef C�,� in 3jr—s
PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION.Of ENVIRONMENTAL HEALTH SERVICES
PERSON INTERVIEWED
amen
DATE IO O
PROPOSED INSTALLER
ADDRESS 02f .774 d'i,
OFFICLAL USE ONLY
TM #�
Ja PHONE
PCHD Complaint #
e ati ip i.e., owner, tenant, etc.
TYPE FACILITY 17ev,.
PHONE (y��-1 dWf
REGISTRATION# 9�
Propmal (include sketch` 6cating 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.
_ -. - - - .. - - -poi,► �D/_' P �'G��DdIGI ��°���i -C - �i9�I�t' -R'i --- C'� / /2°� _
I, as owner, or re prte gent of owner agree to the conditions stated on this form.
SIGNATURE
ho TITLE � DATE J�w
Proposal 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 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.
Proposal approved z
J�ls� i / /-1 /06
Inspector's Signature & Title DATE
COPIES: White (PCHD); Yellow (Town BI); Pink (applicant)
PC -RP 99ML
PUTN,AM COUNTY HEALTKDFPARTMENC
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
PROPOSAL FOR SEWAGE DISPOSAL SYSTEM REPAIR
❑ y o.
❑ . ` pair vvift Boy.ft Comer% W_ Rmnph or Croton Falls Res:,'. � 1581egated rshe •.. 4 .: . ; • .' ' - � �.�.,
.,
1 , _ pa a am wunn or ucu•rnappea waoana V JVII Et RCYICW 1 .
a ,
wr
AM Co. PUTNAM COUNTY ,,HEALTH DEPARTMENT
� y DIVISION OF �NVIItONMENTAL HEALTf SER�7ICES` ;r' � t,,c�w w � k�� � r cs
* *
PROPOSAL FOR SEWAGE DISPOCA? SYSTEM REPAIR i `:
_
OFFICIAti.IJSEon
.. t +.i S 4 't r (;,F x•r. ^k N%` k "- .w ,.'4 . a } N�n a A.. u�'(��.
SITE LOCATION
OWNER IS NAME ' d PHONE o3a 9
MAILING ADDRESS
N PERSON IN ERVIER!ED / /.dPf L/ Gb : , PCHD Complaint # F , r -�
7.
ame a Latl n ip i e, owner tenant etc �' ' Z
DATE IO 0 TYPE FACILITY
- S --- _ 7 v 4
PROPOSED;INSTALIER �V C' d}f lrl rl�l PHONE
p
ADDRESS
Proposal (include sketch cating all adjacent wells)
,,OT f7Et Repair must be in same location and of same type as ocigmal sewage dispgsal system Different location' �" „< { ^k ` J;
a
may requtm siibmitial.gf p�opgsal froia.licepsed p gfessional engineer or registe ed architect
z
c � , e . �� �
ut
5 -'z d _
r,.,r�
'fit �?� � Y•n'�uus �'+ y_„- +'}"Km` «J �xa,'v .,� ,.� .�+ `^'r.'.... r' 'Sh � r� �o T a � x.. ` ' � u�+" 't ��
° I, as owner, or re rte entof<'owner agree to the condihons.stated onrtlus form'
SIGNATURE TI7LE C ,1�L %� y DATE
Proposal apoved with the folio- condirions c '' w r
1 Prociirement'of f licable e * r•h ` .�, � d ry, � 9 a F r i
any Town' permit R.
app ; y
2 5ubmisSion or as built repair sketc�l m duplicate showing #` .
N� a a ,Owner S' name, vP f , °ua� w� a { ,�"� S , u,>F 5 .f k rn 3i r « �^tt'{�`Si ,a '�9
b Site Street Name,; Town and Tax Map number 9 y
= c Location of installed rAmponents 4W to two fixed polls (tee g house comers) r €
d, : System descnptibft (e g 1-250 gal` r Concretesepttc tank; three precast 6 dam -ix '6 deep
e Installers name and number e i
3 System
Prop rep bo O sa odUar to be p ormed in accordce wih he a--d
r
t
r 5
r p
f a* - .....%��/_�0:�7..».._._ w1::�5 _sue" .y o . •? . , •r .w iv.`�i�` \i:
Inspector's•:Sgnature && Title
�, COPIES y✓lute (PCHD) Yellow (Tovm'BI) Pmk�(apphcant), � 5 •"�, r ��," r
PC RP 991 i
y a` 7aNY^ W v
a
t
p � 4
n r '
rn:.'. � ;� r.:. ir5 �' wf''e;•.
F
P k 1 T Y
f 5
DAATE
iu. %rp 4u� "i.�,p�� }l x �`o Ff ��Rd,• �� +s' �',° ° r ;^'' El e �i
- \ A.. C .
t
3 k
d. e
t :3
v
1 ,
41
-4
TR I
c"
C DE COLORES 33
DR
I CA Lh 7,
RD e i 8P $ Lake
W S?'DGE
WAINWR
Uo
Fp
oT
'A
aGIVY
CD
C/)
am
C"
SARAETT
r � tla I
Ze
Oki
1 ANY
0 X
CLIFTON
10.
O
RD
c o
ao
0
AS
4 4,>,
41
§AUSABLE
0
1 RD
LIVINGSTON RD
N C HAMILTON
DR o i
ARR RD QENEVA
DR
3
DR 1
V4
DR
3s
C)
LUD,
Ilk
oklooNoo
CLIFTON
10.
O
RD
c o
ao
Noveffiber 2006
rq
Permit# R-275-06
i
209499 251899
yi...........
I
Simpson
486 Fair St
Carmel NY
Tax map # 340134-14
Precast concrete 1,000gal
septic tank w/ 1411 riser
7WkAWW77&A! KAWJW
b- . alf"Va ITAWRO ® -.4
1-4
209499 251899
yi...........
I
Simpson
486 Fair St
Carmel NY
Tax map # 340134-14
Precast concrete 1,000gal
septic tank w/ 1411 riser
7WkAWW77&A! KAWJW
b- . alf"Va ITAWRO ® -.4
5 ? w I
_ _ �..
•EY' �e� -�' 444 ';' p Ci:�'�
J
� x� '�.`+` may'`+ •�%s�'s'. ".
�S�'c 1
iT
y�
\
^i s
�-r jCs
'ti
;= n
_ _ �..
•EY' �e� -�' 444 ';' p Ci:�'�
J
� x� '�.`+` may'`+ •�%s�'s'. ".
�S�'c 1
iT
y�
\
^i s