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HomeMy WebLinkAbout2876DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 62.13 -1 -62 BOX 24 Im L il.Wd Sill � ..' , 02876 f SITE LOCATION OWNER'S NAME MAILING ADDRI= _ _.. PUTNAM COUNTY-HEALTH DEPARTMENT DIVISION OF ENVIRONMENTAL HEALTH SERVICES - FRUFnS4:tL- FQIt ($- DJSP_Q$AT. �l'��. OFFICIAL US ONLY - P� � -00- I- 6 a 2)s-72, PERSON INTERVIEWED U A k--,;E 5-EA R 0 o uJ N� R • PCHD Complaint # Name & Relationsaip i.e., owner, tenant, etc.)_ DATE TYPE FACILITY 06 04 1 E HONE-- PROPOSED INSTALLER J-�p OA lZ ►(J ► S ©►JS PHONE Q RE ADDRESS (1��p� '�,Q1�i= r��l���tl GIST Ob RATION# 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. I, as owner, o r ported agenfff er a ee to the conditions stated on this form. SIGNATURE CL 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. DATE COPIES: White (PCHD); Yellow (Town BI); Pink (applicant) PC -RP 9%E .4, PROPOSAL SUBAA To* . mW_RW.Qm crry.STAT end ZIP (ODE ARCHITECT ff .We hereby Sub I 7o 11ULIN I Y I IKIL tlu PAGE 02 POW No. of Pap WC NSTRUCTION, INC. F4 vlw a CORD ANIDT .MANOR .MY -T-96 92 -Nt30 a UC. k PC -560 JOBNAME. m LocA nON I JOB PHONE '40 Material 13 RUan -deed-lb 'be aa-4 Mat"ra=rdN to ftnlard waco�o kw*&g extra coga YWII be exeou* 2, charge over and _4% r- tho osft* or delays beyond a Our m r c6nW..Ow.njc: Wo*qm are covered tri. vii� Arreptaut of and conditions -a satisfactory.' J .."J, Mam Qou-nty,-W%UI3-D_ep.artm,.e.nt. Date of Acoaptan 11ULIN I Y I IKIL tlu PAGE 02 POW No. of Pap WC NSTRUCTION, INC. F4 vlw a CORD ANIDT .MANOR .MY -T-96 92 -Nt30 a UC. k PC -560 JOBNAME. m LocA nON I JOB PHONE complete mplete in accordance with. abo* Ve specifications, for the sum of: dollars ($ .;4. MONT10VILI DEADDED70-ALLLOMIDBALAWDES.. 94 FAAM409 40061.144. A-048 A�L 004;kWRON FIECE& 7 ALL bl ARE TOHip BINDI=AnoN. signature Note: -Tift proposal may be withdrawn by us ff not accepted Within days. ie cii; �io-s' dtl{lf10[f Ed anatum Signature - A,!5 4,/,,c riZ✓ -7 2, -06*0i..County Department of Health W h Q Kor, lo' n 6t Environmental Health Service P;, a as noted for conformance with �lk­aide Rules. and 136c0ations ofthe J .."J, Mam Qou-nty,-W%UI3-D_ep.artm,.e.nt. Signature & Title • llllmytOTHEA THAN GRAOM DISTURBED 54P�P;MESS SEOMCIALLY 8T.ATW..* complete mplete in accordance with. abo* Ve specifications, for the sum of: dollars ($ .;4. MONT10VILI DEADDED70-ALLLOMIDBALAWDES.. 94 FAAM409 40061.144. A-048 A�L 004;kWRON FIECE& 7 ALL bl ARE TOHip BINDI=AnoN. signature Note: -Tift proposal may be withdrawn by us ff not accepted Within days. ie cii; �io-s' dtl{lf10[f Ed anatum Signature - a DEPARTMENT OF HEALTH 1 Geneva Road - • Brewster, New York 10509 Ea%ironmental Health (845) 278 - 6130 Fax (84 278 - 7921 .... • +r... -S-� —• �•. —.�.: .v-.:? 4 - .. .na. .err.. - .. .. � a . ... �c ..� ..•�.e... �.. . .. r- n . .. vi rw — a i h. facsimile transmittal To: .��.a� -,�-i Fax- 7'1`1 - y? S? — / J� From: �6_ Date: Re: Pages: CC: ❑ For Review ❑ Please Comment ❑ Please Reply ❑ Please Recycle /�v �Sa� vim` P zL�� . In the event of transmittal difficulties, please contact this office. . 0 . . 0 0 . . 0 0 . . 0 0 . 0 0 0 0 0 . 0 . 0 . 0 0 0 SITE LOCATION OWNER'S NAME MAILING ADDRI PUTNAM COUNTY HEALTH DEPARTMENT DIVISION OF ENVIRONMENTAL HEALTH SERVICES ..: P tf3PaSEl►I, TOR S;e; i%ti Z FdSAL SiSl Sidi OFFICIAL US ONLY -00 PERSON INTERVIEWED U A QE 64 _OA 1, 0 o Ly Q�_ R• PCHD Complaint # ame Relationship i.e., owner, tenant, etc. _ DATE 'I-1q-0\ TYPE FACILITY 06 0 k_1 E i-} O N � PROPOSED INSTALLER PHONE 9/q 2 (0 _ 9() ) (� � ADDRESS � 040� 02 , � , r�1 ��c�-� -i 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. I, as owner, c SIGNATURE i Vee to the conditions stated on..t_his form. L-- 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 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. DA'L'E COPIES: White (PCHD); Yellow (Town BI); Pink (applicant) PC -RP 99ML PUTNAM COUNTY HEALTH DEPARTMENT DIVISION OF ENVIRONMENTAL HEALTH SERVICES ZO T-EAT`--=�P` -PROPOSAL�WWWWAGE Da-12 Sidi OFFICIAL USE ) ONLY SITE LOCATION .St-I TM# OWNER'S NAME PHONE C� MAILING ADDRESS �,,)EL" PERSON INTERVIEWED * -1 .1 " 11 t - ` C. t -) t i (- PCHD Complaint # Name & Relationstup (i.e., owner, tenant, etc.) DATE TYPE FACILITY PROPOSED INSTALLER PHONE ADDRESS f- 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. as owner, or reported agent of owner agree to the conditions stated on this.form, A. SIGNATURE TITLE ; _. _.. a DATE .. .... `t r — - �J Proposal approved with the following conditions: 1. Procurement of any Town permit, if applicable. 2. Subr M"ssion of as built repair sketch in duplicate showing: a. wner'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 6diam. 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, COPIES: White (PCHD); Yellow (Town BI); Pink (applicant) PC-RP 99ML .,DATE COMNIENCE WORK PERNUT PERMIT ISO.: 2001 -120 DATE: April 19, 2001 TM#: 62.13 -1-62 ORIGINAL INTO.: LOCATION: 34 HUDSON VIEW DRIVE ISSUED TO: SHERMAN LAWRENCE A & DIANE ° An application having been properly filed for new construction, addition(s), . alteration(s), repairs as per the attached specifications and plans, I hereby grant such application upon the following terms and conditions: All work must be done in accordance with the plans and specifications annexed to the application and shall be located precisely as indicated on the plan(s) and /or survey All work shall be in accordance with the Uniform Building and Fire Code of the State of New York and all pertaining County or Town regulations All electrical and plumbing work must be done by contractors duly licensed by the County of Putnam. "dppcakil "e; "" "Home` Improvement Contractors' license will be required. This permit is issued for the following: Permit to cogmwnce work COMMENT: replace septic tank - same location DOTE: THIS PERMIT EXPIRES ONE YEAR FROM DATE OF ISSUANCE TOWN OF P1JTNAM VALLEY, NY Alp By CODE ENFORCEMENT OFFICER