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Home My WebLink About2865DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 62.13 -1 -25 & 62.13 -1 -29 BOX 24 h . i !jJ6 k ` = :. , 02865 _ 4 PUTNAM COUNTY HEALTH DEPARTMENT DIVISION OF ENVIRONMENTAL HEALTH SERVICES PROPOSAL FOR SEWAGE DISPOSAL SYSTEM REPAI OFFICIAL USE ONLY �7 -a3 SITE LOCATION �6 3 -�A m eS .> K FPUZN Am Vp LLeY TM# 6 Z 3 — '" 49 r OWNER'S NAME 4 d RC S C P6TP-I CIA K CZ L A Is PHONE 8 9 5%. 5- A 6 — 3 58 MAILING ADDRESS 63 A AMES DP, 'TVinJ AM 1JA LLGY My � 1057'11 PERSON INTERVIEWED PCHD Complaint # Name & Relationship i.e., owner, tenant, etc. DATE TYPE FACILITY PROPOSED INSTALLER L e-z) y "t -4i ci- PHONE i%q 7 36 i of o yg0 5 -5 iz ADDRESS 6, [.� +ro� v Or 0r-+44Ly J-f Ntar REGISTRATION# PIC 5 [, ) 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. 3-6 i I, as owner, or revort,^,d. agent of owner agree to, the. condiiio:�s. stated..on this.fc ryn.. -- ..... _ SIGNATURE 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 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. Proposal approved_ Inspector's Signature & Title D TE COPIES: White (PCHD); Yellow (Town BI); Pink (applicant) PC -RP 99ML ImnaffliaSon Leonardi & Son Construction, Inc. Ca it' IL Cordandt Manor, NY 10567 FAX: (914) 736-9010 (Zil 1 ZL CC, fi .a .. ............................... . .................................. I................. .._....... v.....:.'......, ......... .:..-.::s.— .-....,•:.��.— R —. •. CONST. ROOFING LAND Dimension of Building Wood - � Wood Shingle Paved 2 F'a ",mily Steel Asb, Shingle Dirt Width Depth Stories Type Foundation .......................... ............................... Size & Use, Each ....... .............................................. Room witl. Window Area .................................... Sewerage Type .......................................... Size of Septic Tank ................... ............................... . Lineal Ft. Drainage ..................... ............................... Size of D:j Wells ..................... ............................... Plumbing DescripNc,n ................................ ............................... Well Description................................ ............................... Additio: al Information ........................................................................................... .......I..........•............ ................. This api'Aication must 6e accompanied by a copy of surveyors map and complete plans, specificat ons and all information required by the Zoning Ordinance and Sanitary; Code. of the Town of Putnam Valley when requested by inspector.. Fee $..... . .. .......::.........::......... Building . Estimated Total Livable Area ................. ................'..........Cost $ 450. $..::........a.Q...�Q...... Sanitary Date Zoning Board Approval ........ .................................. ............................... Plumbing- 2_ lumbing j 2 13 -� -zs $... a ............................... Well 1� t5 - 4 .. _ _ lk j _. _.......... . • �........ �...... ,.. fir........ ........_. - -- - 0 • ... xis!.._.. ....: G �� c. _ USE 1 Fa.nily 2 F'a ",mily Steel Asb, Shingle Dirt Log,iCabiri Brick Tile Oiled Bungalow Concrete Metal Swamp Apartment Stone Brook Sto y FNDTNS. INTERIOR. Lake F. Stoic & Apt. Stone Rooms Dams Store & Office- Concrete Apt. Rooms Sw. Pools Office sBlo`cks Apt. Ten. Courts Gas ;Station back Attic Open . . . Garrge Piers Attic Finished OTHER BLDGS. i EXT. WALLS PORCHES, Barns........ BASEMENT Wood X Front Shacks Past , Brick _ X Side _ Cottages Fuli' ' Brick Van. X Rear Bungalows Cement, Floor Log. X Erich -:= Electric Finisied Shingle MISC. Phone Garrge B. In.. Comp. Plot Plan Furnace Field Stone Driveway Type Foundation .......................... ............................... Size & Use, Each ....... .............................................. Room witl. Window Area .................................... Sewerage Type .......................................... Size of Septic Tank ................... ............................... . Lineal Ft. Drainage ..................... ............................... Size of D:j Wells ..................... ............................... Plumbing DescripNc,n ................................ ............................... Well Description................................ ............................... Additio: al Information ........................................................................................... .......I..........•............ ................. This api'Aication must 6e accompanied by a copy of surveyors map and complete plans, specificat ons and all information required by the Zoning Ordinance and Sanitary; Code. of the Town of Putnam Valley when requested by inspector.. Fee $..... . .. .......::.........::......... Building . Estimated Total Livable Area ................. ................'..........Cost $ 450. $..::........a.Q...�Q...... Sanitary Date Zoning Board Approval ........ .................................. ............................... Plumbing- 2_ lumbing j 2 13 -� -zs $... a ............................... Well 1� t5 - 4 .. _ _ lk j _. _.......... . • �........ �...... ,.. fir........ ........_. - -- - 0 • ... xis!.._.. ....: G �� c. _ PUTNAMCOUNTY HEALTH DEPARTMENT DIVISIOMOF ENVIRONMENTAL HEALTH SERVICES SITE LOCATION ..1AM�,S ]> K PVTvAm V, 6UtYTM# 6Z.13-1-4q z OWNER'S N AME E PA-7 PLIA ' E- L A S PHONE F45-- 5 a 6 - 3580 MAILING ADDRESS Dk ?Vi 0 PAS VA UeY -+U`e r 10 5 7a PERSON INTERVIEWED. PCHD Complaint #, a ne & Relationship i.e., owner, tenant, etc. DATE TYPE FACILITY PROPOSED INSTALLER PHONE ADDRESS r_a i _ , < , 1. i2 „ > REGISTRATION# 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. S6 1, rs ovine, or reported agent of owner agree to the conditions stated on this form. SIGNATURE 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: r`• a. Owner's name b. Site Street Name, Town and Tax Map number. t...Y 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"' eep •Y . e. Installers' name and number. 3. System repair to be performed in accordance with the above proposal and conditions. l� Proposal approved_jN , Inspector's Signature & Title D kTE COPIES: White (PCHD); Yellow (Town BI); Pink (applicant) PC -RP 99NE cz co cr.) co li o O cmi CD COD 0 v I G, le,�Ly, 7 7-z-oy Ov, Dq SW CD2- TA u e-- -N ra w,,A(-.L, 32-7 d. 44 -s g -3 01, -N ra w,,A(-.L,