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02324
PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
PROPOSAL FOR SEWAGE TREATMENT SYSTEM REPAIR
Y—ES-- ... NO ;.- ... internal Use Onl�.;, PERMfT -#-- .. .�.�
❑ pair Permit Issued in last 5 years ❑ t in Watershed
❑ Repair within Boyd's Comers, W. Branch or Croton Falls Res. Del egated
❑ Repair within 200 ft. of a watercourse or DEC- mapped wetland ❑ Joint Review
ESSER
PM C PUTNAM COUNTY HEALTH DEPARTMENT
J�� y DIVISION OF ENVIRONMENTAL HEALTH SERVICES
a
PROPOSAL FOR SEWAGE DISPOSA? �_S_l'STEM REPAIR.
CIAL USE ONLY
SITE LOCATION 571 A g bu f u 5 5r TM# Iq 1.0 10 z 9 I
OWNER'S NAME 34,"t5 6nxm,-r LEE VG PHONE %lam —��93
MAILING ADDRESS 51 jg&iavP ys sr (/04I emu_
PERSON INTERVIEWED PCHD Complaint #
Name & Relationship i.e., owner, tenant, etc.
DATE TYPE FACILITY
PROPOSED INSTALLER .Ziv<_ PHONE 9/9— A7`I'6`a6'
ADDRESS 7 4) L✓vy/I /Ld) cvo•rlr► Oi �by.sn� �, REGISTRATION#
1J 'S62
Pro oral (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.
4 Aft-k/ C r-C- avcfi'ON &j6S
1&0 Lh, of Z' L4-nc. /l _% 7,LC. 41165 .✓i t�h geauvzl
I, as owner, or reported agent of owner agree to the condit7/w- s ted on this form. j
SIGNATURE `— � Al. TITLE 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 (e.g.,house corners).
d. System description (e.g., 1250 gal. Concrete septic tank, three precast 6' diam. X G deep
e. Installers' name and number.
3. System repair to be pe rmed in accordance with the above proposal and conditions.
Proposalapproved
la 2
Inspector's Signature & Title DATE
COPIES: White (PCHD); Yellow (Town BI); Pink (applicant)
PC -RP 99ML
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cQT%GK.AT%owS Sa'AU- FAJr" CM-4W'< to Note: All certifications hereon are in.accordanco
Fae ,,440M TA�- Sv1e -46,r with the minimum standards for surveys as
V.rS %LEo4PW -S adopted by The Now York State Association
b nttra m►;oev �Y P*. to L&�,olr+G of Professional Land Surveyors and are valia
Est �T.+T ow, ustGOea, c68T1c�cpt�o�6 for this map and copies thereol •only if saic
map or copies bear the impressed seat of the
uSTiTvT��r>S eR surveyor whose - signature appears hereon
Unauthorized alteration or addition to thi;
an map is a violation of Section 7209 (2) o
4X.s. t x .,0 405E+7. c° WC- The New York State Education Law.
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FAX NO. :9147883738 Apr. 09 2009 09:40AM P2
FROM':P.jZZELLA BROS BA.2787921 7_6�t P.001/001 F-244
06:2SAN FROJ-DVIRONMENTAL HIALTH
Pur` k tmj):� HSkLTHI DURAFtTIVII .
NT tt
DIVIS1.0N OF ENVIRONMENTAL HEALTH SEFIVICES
THIS M.NOT A REPAIR PERMIT 77
PROPOSAL FgA MELOI!ATION QF P IC SY Tau F14„( 11
All Information below rmu3# be it comolsted prior to any scheduling
s r. LOCA TMON
rr TOWN-RA c j, 1 rm #Y/
OWNEMS.NAME i l Wit' PHONE # YgL14,7193..
MAUNG ADDRESS
PRCPOSED CONTRACTORANSI ALL ER -'qL±739-3 VO S
PHONE
qmW REGISTRA71ON UCENEE
OtBlIWO to 3UtftCJ9 0 132 �-Up in house find ROWS Of SY$t*m far repair 0 *the
P . r (expwn 13*10W)
eof CVJTC.
Irsp . e6iiris S'lonaluft &
Time; 00
Sheet_ of
PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION: OF` -- N�VIRONMENTAL'IIEATLII— ERVI'CES
FIELD ACTIVITY REPORT
�{0r
TNI�PFCT OR � T� % :T'FT ,
Signature and Title
I acknowledge receipt of this report: SIGNATURE:
02/96 Title:
PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
CIAL USE ONLY
SITE LOCATION S71 hgbuju� SD" TM# 41.,010 -z- 'i l
OWNER'S NAME Jilme 5 841,4,vr CEyife, PHONE 160-7ig3
MAILING ADDRESS Sl gn iav7 vs s to'-*An rv�4 10SZ2
PERSON INTERVIEWED PCHD Complaint #
Name & Relationship i.e., owner, tenant, etc.
DATE
TYPE FACILITY
PROPOSED INSTALLER j;Z2x / %,� Altos PHONE ffL9'- 2?9°6GaeF
ADDRESS -)1)6g Z-,/Od/ /1.l) c--o` l»NOi ,- �REGISTRATION# /Q �(
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.
4 Mtke &x6S
160 '-/F _o{ z' L�nciti4'� -, TiL��v�/i &i ,;✓i as -c�u�l
5
_._._,T; as- ovvher`; .oxzeported agent "of owner agree to the Condit' s ted nnahis form.
SIGNATURE �1LA TITLE -e
Proposal approved with the following conditions:
1. Procurement of any Town permit, if applicable.
2. Submission of as built repair sketch in duplicate showing:
DATE
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 pe ormed in accordance with the above proposal and conditions.
Proposal approved
.44-=!b . ��,Fw
Inspector's Signature & Title
COPIES: White (PCHD); Yellow (Town BI); Pink (applicant)
PC -RP 99ML
DATE
Ucs WC- 4149 -H91 PIZZELLA BROTHERS, INC.
UC#PC -192
SCALE: N T, S APPROVED BY: DRAWN BY:
DATE: 1' REVISED:
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DRAWING NUMBER:
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Ucs WC- 4149 -H91 PIZZELLA BROTHERS, INC.
UC#PC -192
SCALE: N T, S APPROVED BY: DRAWN BY:
DATE: 1' REVISED:
4'
PIT' jArl ILI
DRAWING NUMBER:
Q i0
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