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HomeMy WebLinkAbout2682DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 61. -1 -37 BOX 23 02682 '; : '' Ir 1, . 02682 el., SEP -1i =2007 10:57AM FROM - ENVIRONMENTAL HEALTH 8452787921 T -343 P- 002/002 F479 DIVISION OF ENVIRONMENTAL HEALTH SERVICES, YES ..._ ._,r .. NCB _ ....Internal Use.Only _ _ . . PERMIT # ❑ ig Repair Permit Issued in last 5 years © Not in Watefshed Fl Repair within Boyd's Comers, W. Branch or Croton Falls Res. ❑ Delegated ❑ ❑ Repair within 200 ft. of a watercourse or DEC - mapped wetland 0 Joint:. Review._' SITE LOCATION 184 Sunset Hill Road TOWN .Putnam Valle M # 61.-1-37' OWNER'S NAME Roger L. Raimo & Abigail .G. 'Raimo PHONE # 845- 526 -3133 (h) MAILING ADDRESS 184 Sunset Hill Road, Putnam Valley, NY 10579 APPLICANT Abigail C. Raimo, Owner Name & Relationship (i.e., owner, tenant, contractor) DATE 9/17/07 PACILITY'TYPE PCHD COMPLAINT # PROPQSE,D INSTALLER n PHONE# I ADDRESS e_ R!0515i R ` FION /LICENSE # Proposal (inciride a separate sketch oca ng th 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. Replacement of outlet Baffler to Septic Tank 3;.Z1W< ff-6 4exl 10 I, as owner,agree to Pq conditions stated on rm SIGNATUR �)Z!Z41TLE Owner DATE 9/17/07 (owner) I, the septic installer agree co /theeditions pf•this p for the septic system repair SIGNATURE- ,( Tll'LE 64TE . (installer) 10 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., 9250 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 backflllsd until authorization to do so has been obtained from the Department. 7 INTERNAL USE ONLY Proposal Approved /L� re & Title is in Proposal Denied 0 y Date Expiration Date codes Yes . ❑ No D COPIES: PCHD; Owner; Installer PC -RP 99ML Rev. 2/07 - Abigail C. - Raimo- ...,,_ - : .. - 184 Sunset Hill Road Putnam Valley, New York 10579 (845) 526 -3133 (845) 528 -4410 - work September 20, 2007 Joseph Paravati, Jr.,, APHE Department of Health 1 Geneva Road Brewster, New York 10509 RE: Request for Permit Dear Mr. Paravati: Enclosed i s the Application for a Permit signed by myself and the Installer as well as m y Money Order for $150.00. If all is in order, please se n d the Permit to my address abov e and I will contact ntact Earth Care so that they can prepare the outlet Baffler. Thank you for your assistance and please call me if there are any questions. Sincerely, F Abigail C. imo Enclosure