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HomeMy WebLinkAbout1846DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 35.06 -1 -33 BOX 17 a ir '1 cr k' 1 1 PUTNAM COUNTY HEALTH DEPARTMENT DIVISION OF ENVIRONMENTAL HEALTH SERVICES V .Aft. YES NO Internal Use Only^ V� ❑ Repair Permit issued in last 5 years VDelegated of in Watershe ❑ Repair within Boyd's Comers, W. Branch or Croton Falls Res. ❑ Repair within 200 ft. of a watercourse or DEC-mapped wetland El Joint Review P PP SITE LOCATION TM # . 'I OWNER'S NAME & VY iv r/euZilll PHONE # 2 %y- ( 7,f—Y6 (-!j MAILING ADDRESS T e-1,41 -1)T 'Pa h(eT So N APPLICANT 0l,wt R ' c' V./,- Uu- Name & Relationship (i.e., owner, tenarA , contractor) DATE c FACILITY TYPE Sjn.Glt PCHD COMPLAINT # PROPOSED INSTALLER0,ey- rnPLc �uy,,Z.,T PHONE # (�rvU -�4ZS-G-06'�' ADDRESS y y Mple REGISTRATION /LICENSE # 0 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 trenches) NOTE: Repair must be in same location and of same type as original sewage disposal system." Different location and proposed pump systems will require submittal of proposal from licensed professional engineer or registered architect. )) J ) J I, as owner, or reported agent of owner agree to the conditions stated on this form SIGNATURE TITLE Owe e - DATE 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 d. System description (e.g., 1250 gal. Concrete septic tank, etc.) e. Installers' name and phone number 3. System repair to be performeZinac rdance wi th the above proposal and conditionProposal Approved Proposal Denied zfez Inspector's Signature & 'tie Da COPIES: White (PCHD); Yellow (Town BI); Pink (Installer), Orange (Applicant) PC -RP 99ML Rev, 8/05 { P � NJ. Ea ,, rthCare All County Division . �jP800z8 s _. SEPTIC PUMPING • REPAIRS • INSTALLATION Site Address Name: Address: G c rl City /State:/ Home Phone: Work Phone: Cross Street: County: Twp. Map Coord. Site: Wk Order: Billing Address Name: Address: City /State: Home Phone: Work Phone: Zip: Cell Phone: Payment: Check # Credit Card: Amex ❑ Discover ❑ MasterCard ❑ Visa o Other ❑ Card P Septic Svstem Evaluation & Proposed Action Exp. Date: SYSTEM INFO: CONDITION RECOMMENDATIONS: Tank Type: Conc ❑ Metal o Plastic ❑ /Cass Operating Level U Above Below Recommend Additive �Yes� No Tank Size: ��c> Shape: Drainfield Run Back Yes No Suggest Aeration Yes CDO , �, Depth to Top: to Access: �_ Heavy Sludge Yes Suggest Outlet Cleaning Yes No System Saturated Yes o Suggest Inlet Cleaning Yes �N�7 Drainage System: Toilet Flushed es No Suggest Tank Replacement Yes No Field ❑ Trench o Pits ❑ PD c3 Outlet Baffle Good Bad Suggest Lid Replacement Yes No Inlet Baffle Good Ba Suggest Riser Yes Suggest Reg Maintenance Yes No Dousing Tank / Pump: Yes ❑ No r,( Clogged.lnlet/Outlet , . Yes. No Next Date: Comments /Notes )c All--- � / /), ,, e 0� Customer's Signature. Driver's Signature „�/ •L / % %�< %/� '� Customer Disclosure: In the event of payment delinquency, EARTHCARE Is a consumer reporting company, In accordance with the Fair Debt Reporting and Fair Debt Collection Practices. Reasonable costs associated with the collection of past due or delinquent accounts are the full responsibility of the customer. EARTHCARE, All County Division, will not assume responsibility for damage to driveway or any off road damage. CLEANING: Sept res Lch Sldg Ga FIELD: SP 3 6 9 Digging /Labor Cleaned Line INet Outlet Treatment Cover/Lid Baffle Truck Charge EMERGENCY CHARGE Billing Address EarthCare -All County Div. 99 Maple Grange Road Vernon, NJ 07462 CJ Sub Total �Q Tax Total XT .�''. Amt Paid Great t 64 311 12563 W\ rlMendel Pond 164 mines Corners Pond W Ice 'r �Reinbeci� Pond ? (�� ' � O O � iY _ " 's Po Iter, Pond n IMS Iviland 11h*_ o 114m Farrar 3ent 22) F je r s 17MournEbo ri;ro i —Police I V' —;& a­ I 11�ft Old Southeast Church OMIT AV, 312 0 am 1 m 9 mo s OR t m WAY W—t. N.rth PL see ,.Bog 54 WL P Res m Putn1a, Lake l,j) 6rnum mers Lake � j.'�,,Charles . 11h*_ o 114m Farrar 3ent 22) F je r s 17MournEbo ri;ro i —Police I V' —;& a­ I 11�ft Old Southeast Church OMIT AV, 312 0 am 1 m 9 mo s OR t m WAY W—t. N.rth PL see ,.Bog 54 WL P Res m i Slice of PUTNAM COUNTY DEPARTMENT OF HEALTH ---DJ-,VJS-1ON7.O.F E-NVIRONME N;T-A-,L,-HEA-TL FIELD ACTIVITY REPORT NAAAR, Ted: A", 191Z) 6 -7 1 — Z �5/ Street � Town State Zip PERSON IN CHARGE Name and Title TYPE OF FACILITY: �L? Ad f I NSPEA I HAZ Signature and Title RFPnRT RFCFTVF-T) BY: I acknowledge receipt of this report: SiGNATURE., 02/96