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01634
PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
...PROPOSAL FOR. SEWAGE THEATIMENT�SVSTEM,-.REP/AIR... .-4G _ -1
NW` oc,t l�r Al . Ke' L
YES � Internal Use Onlv PERMIT-# —
SITE LOCATION
OWNER'S NAME
MAILING ADDRESS
APPLICANT
Repair Permit issued in last 5 years
Repair within Boyd's Comers, W. Branch or Croton Falls Res.
Repair within 200 ft. of a watercourse or DEC - mapped wetland
TOWN
G
❑ Not in Watershed
C(..Delegated &AI J
❑ JoiaWeview
PHONE # 'b�" y_57
Name & Relationship (i.e., owner, tenant, contractor
DATE FACILITY TYPE f/ PCHD COMPLAINT #
PROPOSED INST LLER J� /G r``�G ` PHONE #�s—
ADDRESS af
Q!ej '// )J/ REGISTRATION /LICENSE # f /%�
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.. Pt`s N
d1Isk ft see ✓Cow :S£?_� I�`�. �-4ik i �� .r - -. (v c h y.
I, as owner,agree to the conditions stated on this form
SIGNATURE `
���� , TITLE a u��/` DATE �
(owner)
i; the septic installer, ag ee'to comply withethe conditions-ofthis permit for the - septic system epair
SIGNATURE y� TITLE DATE Lv O
(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.
1171 CA17AL. VOC %JML.T
Pr osal App ed Proposal Denied ❑
16/3,V01 ir, 0
In pector's Signature & Title . Date Expiration Date
,Repair proposal is in compliance with applicable codes Yes ❑ No
COPIES: PCHD; Owner; Installer
PC -RP 99ML Rev. 2/07
Sheet of
'PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL: HEATLH SERVICES
FIELD ACTIVITY REPORT
NAMT F: �G�M -�S Mac 09'1e,,,i TPI:
Street Town State Zip
PERSON IN CHARGE
nR TNTFRVTFWFD
Name and Title
TYPE OF FACILITY: - /L., -s ;"k,t S S 7S
t,7 /0e
F I ND I NGS : / K-e-t -✓
S�,dnature and Title
I acknowledge receipt of this report: SIGNATURE:
02/96 . Title;
SITE-LOCATION
OWNER'S NAME
MAILING ADDRESS
APPLICANT
PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES �4
AL-:f R; SEWAGE- TREATMENT'SYSTEM REPRAIR •:
Internal Use Only PERMIT
Repair Permit issued in last 5 years U Not in Watershed..
Repair within Boyd's Corners, W. Branch or Croton Falls Res. .Delegated7rJ
Repair within. 200 ft. of 'a watercourse or DEC - mapped wetland ❑ Joiyt�Review
72,41�z6ez&)r-- TOWN 1Y1 }t
PHONE #
G
Name & Relationship (i.e., owner, tenant, contractor
DATE FACILITY TYPE / f/ o _ PCHD COMPLAINT #
PROPOSED INST LLER -� ?" /G 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. , 11
I, as owner,agree to the conditions stated on this form
SIGNATURE TITLE Q u.,'4{/` DATE)
I, the septic installer, agree to comply with the conditions of this permit for the septic system epair
SIGNATURE TITLE +'- DATE
(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.
u�rnu w ic+r Man v
11\ 1 GnNML
Proposal App ed Proposal Denied ❑
Ih ector's Signature & Title P�" Date Expirat n Date
Repair proposal is in compliance with applicable codes Yes ❑ No-
COPIES: PCHD; Owner; Installer
PC -RP 99ML Rev. 2/07
11
MEMORY TRANSMISSION REPORT
TEL NUMBER 8452787921
NAME ENVIRONMENTAL HEALTH
FILE NUMBER 112
DATE OCT -30 03:16PM
TO 819147730343
DOCUMENT PAGES 001
START TIME OCT -30 03:16PM
END TIME OCT -30 03:16PM
SENT PAGES 001
STATUS OK
FILE NUMBER 112 * ** SUCCESSFUL TX NOT ICE * **
PUTNAM COUNTY HEALTH DEPARTMENT
nIVISION OF ENVIRONMENTAL HEALTH SERVICES
1-,r0 - �J-
tnierrtal I.iSe Only PB02iL81T 0
Repair R—n i—uad in last s yearn LJ Not In Watershed
Q Repair within BOYO'e Comarc..W. Branch cr Craton Fall$ Res_ !�L relegated '% O'^j LtJ"
Re it wltttln 200 K. o} a wntareourse or OEGmappeC wetland ,1 OIpt1 evieW
SITE LOCATION -722 TOWN
OWNER'S NAME / - /�m.� S' J7'�4� %�i�+.- `i�I PHCNE #
MAILING AIDORESS -
Name 8e, Rattttion.nip (1.e_. owner. tenant, ooneactor�
[7AT Zr) E ^ -2 �-4 PCHO COMPLAINT #
,,. PROPOSED INSTALLER %G -" r- • PHONE til -
ACI�RESS REGISTRATION /LICENSE #
Proposal (Include a separate sketch locating t1he hoaase, property lines, all adjacent wells wlthin 200
feet o4 repair and the location of axJSting and proposed 9ystern)
NOTE: The 0epartmerit may require submittal of propr,01 from licensed professional depending on the
nature anti extent of the repair_ .� ���y,� j�� -•-s h `
♦ve Sfi. !/ s -�...i �c�i[�CJ -� f �` Soy.,7i -� /S-w Lem i ✓� f - - C � �+-- h Zs- --- '
1, as owner.agrea- to the conditions stated on this form
SIGNATURE `/ �im� �? =-v' z �� TITLE % �J �11�'"' oATE A9,,--2
(owner)
1, the septic installer, a e to comply with the conditions of this permit for the septic system epair o/
SIGNATURE = 0 �...�..�_ TITLE e,-7 DATE
(lnstailesll')
Provo 1 Boor 'Wed with tha following lWan_•
I . Procurement of any Tawn 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- Ownars name, Site Street Name. Town and Tax Map number
b. LOcattlon of Installed components tied to two fixed points
e, System tlescrlptien (m-g.. 1250 gal. Concreta septic tank, etc -)
d. Installers' name and phone number
3. System repair to be parformed in accordance with the above proposal and corlditlons
4_ --he proposed SST. repair is considered a best fit design and there is no guarantee to the duration at which the
completed SS TS repair will function.
S. No completed work Is 10 be bnclMlled until authorftotlon to do ac has been obtained from the Department.
INr6RNAL tJ36 OtdLY
Pr oral App ed /� Proposal Denied
lip actor's Signature, P Title Date Expire n O t�
Re air proposal is in com Hance wttlt aPplicatile, codas Yes M No-)33-
COPIES: PCH17: Owner. Installer
PC -RP 99ML .
Rev. 2/07
MEMORY TRANSMISSION REPORT
.,,,.::::_.._.._._. .,.._. .., .: - � _,ri... -- ;-,:�:.... _. ,:.: _ -_-,,.;.:;-. OCT'- 30'- •2089u- <03:<15PM...e. - _ .. ._.
TEL NUMBER 8452787921
NAME ENVIRONMENTAL HEALTH
FILE NUMBER . 111
DATE ' : OCT -30 03:14PM
TO . 819146288708
DOCUMENT PAGES . 001
START TIME : OCT -30 03:14PM
END TIME . OCT -30 03:15PM
SENT PAGES . 001
STATUS : OK
FILE NUMBER : 111 * ** SUCCESSFUL TX NOT ICE * **
PUTNAM COUNTY HEALTH oEPAFRTMENT
E>IN/ISIC>N OF ENVIRONMENTAL HEALTH SERVICES
AA-7-0 DI-6- � r✓G �Intarrtal use Only PERMIT #
(] Rapalr Permit issued'ln last 5 years LJ Not In Watershed
L:j Ftepelr wfthln Boyd•s Corners, w. eranoh or Croton Fail. Rae. ��Delegated 77� . p N Lj
C7 Repair within 200 ft, of a wateicoursa or OEGmnppad watland JOi evlew
SITE LOCATION J /cal o�rJ �� TOWN _
OWNER'S NAME C %hG� C �i_s, P� NE # M. MAILINCB ADDRESS r
APPLICANT iii
Name & Relationship (i.e_. owner, tenant. contractor,
FAC11...I7Y TYPE �( J -��. -� l_,Q5F!: PCI-40 COMPLAINT # !�+
• - -PROPOSED
Proposal (inclatda a separate sketch locatlng Vhe house. property lines, all adjacent walls within 200
feet'of repair antl the location of eacleMng and proposed system)
NOTE: The Department may require submittal of p`ropgs� from licensed professional depending on the
nature and extent of the repair. M1� -
. rt sf>- � i , -�...� ��a� a._� DSO n �i'• r+- .,...1! i ✓� s - L � 4._ l-� y .._.
I. as owner,agree to the conditions stated on this form ,
SIGNATURE L /�n..._.,�� 9 TITLE
(owner)
1, the septic lnstail er. a p to comply with the conditions of this permit for the septic system apalr o�.
S1(iNATURE - J�-+� -0�•fr 'f �. -.o._ TI'T'LE
(instaliar)
eC!"tr` gal aoortoved wit!'t t_ha following conditions- -
1 _ Proeuramarr[ oT any Town Pamrtt, fT applicable.
2. Submission of as built repair sketch by the sceptic system Insteiler within 30 days of the repair. in duplicate showing:
a. Owner's name, Site Straat Name, Town and To— Map ntJmber
b. Location of Installad componento tied to two fixed points
C_ System description (e.g.. 1290 gal. Concrete septic tank. etc_)
d. Inslsllers' name and phone, number
3_ System repair to be performed in accordance with the above proposal and Conditions'
4_ Tho proposed SSTS repair is considered a bast fit design and there is no guarantee to the, duration at which the
completed SSTS repair will function.
S. No completed work is to ba backfiiled untli atrVtorimtton to do so has been obtalned from the Oapartmant_
Proposal Oenled
Cate
COPIES: F-C'"C; Owner: Installar -
PC -RP 99ML Rev. 2/07
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