HomeMy WebLinkAbout2036DOCUMENT CONVERSION SERVICES PROVIDED BY
IMAGING & MICROFILM ACCESS, INC.
www.scanyourdocs.com
631- 589 -8100
36.40 -1 -54
BOX 18
02036
SITE LOCATION
OWNER'S NAME '
MAILING ADDRESS
A
PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
PROPOSAL FOR SEWAGE DISPOSAL S_ YSTEM REPAIR
OFFICIAL USE ONLY
R,/ ��. mac✓ sfe r TM#
r✓ PHONE C .z7ri- /0 c<
PERSON INTERVIEWED PCHD Complaint #
--game Relationship i.e., owner, tenant, etc.
DATE 3 cx v 2- TYPE FACILITY
PROPOSED INSTALLER �� 0-21--Z S.44c.' PHONE ? ,-r� 6 2
ADDRESS J G ?,2 c-t C k S J Iq f f Q tJ "R-R REGISTRATION# '33-"0
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.
cS.k-, r 7t
.... _ _._..I, _as.oWher ;:.or reported agent of owner agree,-to the conditions. stated on this form.
SIGNATURE / - �� TITLE C%t ✓�.r r DATE �c��. -Z
Pro op sal 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.
Prolosal approved
Inspzctor's Signature & Title DVM
COPES: White (PCHD); Yellow (Town BI); Pink (applicant)
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HEKLA CONSTRUCTION, INC.
Full Service Excavation • Site Work • Trucking
Septic Systems •Sewer Hook -ups
Top Soil • Fill • Gravel • Blacktop
Modular or Stick Built Homes • Foundations
(845) 628 -5066 ; Fax (845) 628 -0128
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If decrease or no change continue
III. Percent Increase In Living Area
a) existing square f0otage.of residence .
% Increase
If leas than 50% continue
IV. Total number of existing rooms
'
Total number of proposed rooms
Will addition affect area available
for SDS
Size of existing 8D5 sufficient
Expansion area available (eq. ft.)
SOS area from of physical restraints
eat, % slope
wetland/storm within 100`
surface rook/ledge
wells within 100'of 8DS
SDS within 100' of well
will relocation of well
and/or 8DS improve _
Separation distance
APP_LIC�ATION - ADDITION --(RESIDENTIAL ONLY)
Name: �� r S,� i','hone Year of Original
Street v �� -a ' '� TM #.. Construction
Mailing Address / - Town PCHD Permit
Description of Addition /� 3 z?
Number of existing bedrooms Pr p sed mber of.bedr
A] Square Footage of exi ing house q
B] Square Footage of Proposed Add'-ion
%increase in floor area_ ( A divided y B)_..X'�100
Please .submit this form and the following to PUTNAM COUNTY HEALTN-"DEPX7M_ENT, 4
GENEVA ROAD, BREWSTER, NY 10509, Phone 278 -6130 with the following information.
IF THE PROPOSED ADDITION IS GREATER THAN 15%
CERTIFIED CHECK OR MONEY ORDER
1. CHECK for $100.00
2. Sketch of existing floor plans (all living area i
Non - professional drawing j
3. Sketch of proposed floor plan. (\
Non professional drawing
4. Copy of survey showing well and septic to tion,
knowledge. Include date of installat'o n
contact William Hedges or Robert�Mor • .
IF THE ADDITION WILL RE
CERTIFIED CHECK _
1. CHECK for $100.0
2. Sketch of exis ng fl
Non-professicia l draw
3. Sketch of p.r po ed f
Non professiona dr
4. Plans for the S wag
meeting present co e
6-ding basement, if"any) N.
the " "6est-6f your �} °
Any questions please
.T IN AN APDITIONAL BEDROOM THAN j ��/5
IEY ORPR
or s (all living area including basement, if ny)
p ng .
oor plan.
ing
Disposal System prepared by a Professiona
requirements, may be required. A
OFFICE USE
Comments and /or conditions
Approved by:
Date:
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