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IWS T96
02909
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PUTNAM COUNTY HEALTH DEPARDEW rty' r o3' ?�
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
PROPOSAL FOR SEHIlM DISPOSAL SYSTEM REPAIR
OWNER'S NAME / <Wr,4 2 Y K .9 i t4 p, PHONE
SITE LOCATION W i c.. W o o L. �! a S
MAILING ADDRESS 0 Pifi -M i 4(- L F V 1 �.� � I o g Z 1'
PERSON PCHD Canplaint #
Name & Relationship (i.e, owner,tenant, etc.)
DATE &/--7— C-144 TYPE FACILITY
PROPOSED INSTALLER PHONE _ 6�� 6 0a sy's-
REGISTRATION # l i�
dal (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 fran licensed professional engineer or
registered architect.
/V/ _ '- o (-OF 7—d'0/7 iO T- P71-M V
Proposal raved Proposal Disapproved
ell
Inspector's Signat a tle 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 oamponents tied to two fixed points (e.g.,house corners).
d. System description (e.g., 1250 gal. concrete septic tank, three precast 6' diem. x 6' deep
drywalls surrounded by one foot + gravel).
e. Installer's name and number.
3. System repair to be performed in accordance with the above proposal and conditions.
1, as ow ner, 'reported agent rf o�r,e..r- agree to Lhe - ie -: sc,.c: itions. -.
SIGIN►ZURE TITLE 46r � DATE 6 ' '
OaW: WAte WD); Yellow (fin ET); Pink Gg l amt)
Pr-pp Q7
t
PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
INITIAL INDIVUDAL ADDITION(REPAIR FORM
SECTION A: GENERAL INFORMATION
Name of Project i'`f' t (T)(V) TMr
Year of Construction Size of Parcel
SECTION B. TOPOGRAPHY (Please check all appropriate boxes)
1. tee
OH/ifly'ORolling e Gentle Sloe ®Flat
� P Slope U P ��//
2. vidence of wetland �1 ou�w�.,^, ab pct to hooding, C13odies of water LL
11rainage ditche Rock outcrop t
(YES/ hI.O
3. Property lines evident?
4. Water courses exist on, or adjacent to parcel: '
5. Existing individual wells within 200ft of the existing SSTS? lJ�'
SECTION C. EXISTING SUBSURFACE SEWAGE TREATMENT SYSTEM(SSTS)
1. Physical character of existing SSTS area.
A. Mvel ❑Gentle Sloe ®Stee slope
P P P
B. OWell drained ❑Moderately well drained
nsomewhat poorley drained ®Poorly drained
C. Area available for SSTS. (Primary & Reserve) _
} ;✓xtremely limited USomewhat limited Adequate _ft x ft
PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
PROPOSAL FOR SEWAGE TREATMENT SYSTEM REPAIR
MAILING ADDRESS
APPLICANT.
3 \W,\&S�mM 219.. R TOWN TM # 1`�`" r �
%PONE # R\-)- Sot- IkO6
Name & Relationship (i.e.,
DATE �,� a_�p FACILITY TYPE PCHD COMPLAINT #
PROPOSED INSTALLER j J Q`��,� PHONE #
ADDRESS QO V B REGISTRATION /LICENSE # kV
Proposal (include a separate sketch locating the house, property lines, all adjacent wells within 200
feet of repair and the location of existing and proposed system)
I:0- TE; Tho Dopar€ment_ ray rsquira A.ubmri-ttal•U -1 Nro��use6`ile�ri� itcer seit 'pro €sssicnai-c�spertdiri ari: tiie.'. _ - - -. _... -_
nature and extent of the repair.
I, as owner,agree to the conditions stated on this form
SIGNATURE ITLE p w�.n../ DATE
(owner)
I, the septic gre
installer e to comply °with the conditions of this permit for the septic system repair
SIGNATURE TITLE Q4A,',-. DATE
(Installer)
Proposal approved with the following conditions:
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., 1250 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 backfilled until authorization to do so has been obtained from the Department.
IurcouAI I so= nul v
Proposal Approved Q� Proposal Denied ❑
Inspector's Signature & Title Date Expiration Date
[Repair proposal is in compliance with applicable codes Yes O -No
COPIES: PCHD; Owner; Installer
PC -RP 99ML
Rev. 2/07
NOT TO SCALE
NOT TO SCALE
NOT TO SCALE
63 Lakeside A
O
Well
Tank to Well A 120'
Tank to Well B 90'
Tank to Well C 115'
Anthony Goicolea
3 Wildwood Lane
Putnam Valley NY 10579
Lake
3 Wildwood LanE!
B o Well
Septic Tank
i
Driveway
R
All Measurments approximate
7 Wildwood Lane
C o Well
10'
Q.
IN
a4i
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TM # 62.15 -1 -28
R- 113 -10
B3 Lakesid� AC
Well
Tank to Well A 120'
Tank to Well B 70'
Tank to Well C 115'
i'
Anthony Goicolea
3 V'Uildwood Lane
{ Putnam Valley NY 10579
Lake
3 Wildwood Lane
E D
B o Well
1
Dr eway
House Corner D to Septic Tank 87'
House Corner D to Distribution Bc 95'
House Corner E to Septic Tank 58'
House Corner E to Distribution Bo 54'
Septic
Di- nffibuti
•i.
1 '
1,000 gallon poly
Box
All Measurments a()proximate
�i
? Lanv
C c Well .:
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