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Home My WebLink About2986DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 62.17-3-11 BOX 25 '1 ' `' �' , T r� • 7 ' 1 I. )V -1T -2008 01:28PM .ING ADDRESS E FROM - ENVIRONMENTAL HEALTH 9452787821 PUTNAM COUNTY HEALTH DEPARTMENT DIVISION OF ENVIRONMENTAL HEALTH SERVICES TOWN &i4ftLh 6 T -240 P.001 /001 F -640 Name & Relationehlp [.e., owner, tenant, cant ac * 107kd FACILITY TYPE CS�t+lx- PCHD COMPLAINT ff POSED INSTALLER &Wcwt— r i•�(p i�%/ i�✓ PHONE # t� ,S". (d' cjc�Q7� a �/`y''� r RES6 i.-�G �iit� ��N' �1�/% REGISTRATION /LICENSE •# OOC 0 -57 13 2sai (include a separate sketch locating the house, property lines, all adjacent wells within 200 Rgyo` � yf repair and the location of existing and proposed system ) C / The Department may require submittal of proposal from licensed professional depending on the e and extent of the repair. el l rl M Cj 16q / 'y). C ywner,agrea to a conditions stated on this form ATURE "1' TITLE DATE 1 - . / `-444f�_ �r) see! Installer, agr 0. comply with the conditions of this permit for the septic system .repair., _. `' UR TITLE .. i . DATE f afar) ,al approved with the following conditions; -ocurament of any Town Permit, if applicable, ibmission of as built repair sketch by the septic system Installer within 30 days of the repair, In duplicate showing: Owners name, Site Street Name, Town and Tax Map number Location of installed components tied to two fixed points System description (e.g., 1250 gal. Concrete septic tank, etc.) Installers' name and phone number stem repair to be performed in accordance with the above proposal and conditions ie proposed SSTS repair is considered a best fit design and there is no guarantee to the duration at which the )mpleted SSTS repair will function. o completed work is to be baokfilled until authorization to do so has been obtained from the Department, sal Approved oe J :tors Signature & I'die in compliance with ?S: PCHD; Owner: Installer ' 99ML Proposal Denied 75 � � pat No Rev. 2/07 A 0 M. OW Local Guy Plumbing / Drain Services Inc. 3 Finch Lane Lake Peekskill, N.Y. 10537 Tel: (845) 526-2471 C-11V V 0. r ib OHM SITE LOCATION OWNER'S NAME PUTNAM COUNTY HEALTH DEPARTMENT DIVISION OF ENVIRONMENTAL HEALTH SERVICES PROPOSAL FOR SEWAGE TREATMENT SYSIEM REP) Internal Use U/ -Repair Permit issued in last 5 years Repair within Boyd's Corners, W. Branch or Croton Falls Res. Repair within 200 ft. of a watercourse or DEC - mapped wetland TOWN LL;V21t r% PERMIT # Vot in Watershed elegated ❑ Joint Review TM # MAILING ADDRESS tr r-, 1.21 at.K r1f &q-h_. �1 � APPLICANT I OVIV9 M44t, G�llh- Name & Relationship (i.e., owner, tenant, contractor) DATE 1 �1i7�� FACILITY TYPE �S/ �-w. PCHD COMPLAINT # X, PROPOSED INSTALLER (�L_GJy ��U+48 ��/(o�/�j1c�ii✓ PHONE # 1Y,rD(o d071 (fyy� ADDRESS 6J /e& &:ra! REGISTRATION /LICENSE # 04C3037 b.), 3 or rte° Proposal (include a separate sketch locating the house, property lines, all adjacent wells within.200 NY 5 -k feet of repair and the location of existing and proposed system) aC / NOTE: The Department may require submittal of proposal from licensed professional depending on the nat a ;and extent of the repair. I, as owner,agre to he conditions tated on this form SIGNATURE DATE (owner) _ I,. the septic instaliar .ague ±�- rompl�; .�ti�i +h,.the rcznditiOns of this.eermit for_the eotic syStF i i BF�av _ ...... SIGNATUR .� TITLE ) 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 Deoartment. INTERNAL USE ONLY Proposal Approved Proposal Denied ❑ 7 Inspector's Signature & It Dad ExI6iration Oate ,Repair proposal is in com piian ce with applicable codes Yes 20 / No O COPIES: PCHD; Owner; Installer PC -RP 99ML Rev. 2/07 6 ° MEMORY TRANSMISSION REPORT Vit i TEL NUMBER 8452787921 NAME ENVIRONMENTAL HEALTH FILE NUMBER 537 DATE NOV -17 11:34AM TO 95262471 DOCUMENT PAGES . 001 START TIME NOV -17 11:35AM END TIME : NOV -17 11:36AM SENT PAGES . 001 STATUS OK FILE NUMBER 537 * ** SUCCESSFUL TX NOT ICE * ** F1UTNAM COUNTY HEALTH DEPARTMI°NT C)IVISION OF ENVIFIONMENTAL HEALTH SERVICES O/ opair Permit lsouac Sn lase a years l � at in Watershed IJ Rapalr -..I. Soyd's Corners, w. Brancn or Croton palls Res. C••r Delegated Q Re wr witnin 200 h, or a wetwcourem or DBC-ma Pad wetland Q Joint FieviOw SITE LOCATION TOW N �O�wir/^r UtFj -ilQ� TM it— _ — (DWNER'S NAME i R✓� C ,y _ PHC)"e IV rrjo "- 3`�A- W MAILING ADDRESS APf�LICANT / /rP"y1'0 Name & Relationship (Lo.. owner, tenant, ocrnraot.r) DATE 1l�/7 / 1=- AGILITY TYP,pE �S- //`-Sr Yi9k^ PCHD COMi, pLpa T # PROPOSED INSTALLER CL�� U %1'�'✓1S."✓�o1o/1�J,.✓ PHONE ss d� Pr000saL (lncluda a separate sketch locating the, house, property lines, all .acljao®nt walls within 20o feet of repair and the location of exdsting and proposed system) NOTE: The Department may require submittal of proposal from licensed professional depending on the net a and extent of the repair. C r llw c7 1, as owner,agree to a conditions Stated on this form SIC3NATUP-iE / !' /j'' 1' (owner) 1, the ae�t't�I_nstaller, agr comply with the conditions of this permit for the septic system repair SIGNATURE �gd�� r TITLEp.�ad/..�— DATE (i 7 Proposal aoorovad yyith the followinc conditions: t . Procurement of any Town Parmtt, If applicable. 2. Submiaslon of as bunt repair sketch by the septic :system tr staller within 30 days of the repair, in duplicate showing: a. Owner's name, Site Street Name, Town and Tax Map number .' Location of Installed cornponants tied to two fixed points c. System desorlptlon (e.g., t aso gat. Concrete septic tank, etc.) d. Installers' name and phone number S. Sy®tem repair to be portormad In accordance with the above proposal and condltions a. The proposed SSTS repair is considered a bast fit design and there is no guarantee to the duration at which the completed $STS repair will function_ S. No completed work Is to be backfiliad untll authorization to do so hem been obtained from the Department. Proposal Approved �3' Proposal Denied DaT COPIES: PCHD; Owner; Installer PC -RP 991%4L Rev. 2/07