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HomeMy WebLinkAbout3027DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 62.18 -1 -36 BOX 25 I m oil 1 ' .. r , . ' I 1� ` ILM I so 1 _ L7 L "r Li r I - ,. , ` 41 ._ ar- %P 03027 C�G� PLFI'NAM OOLRM HEALTH DEPARnOW DIVISION OF MWIRUWNIAL HEALTH SERVICES * * A...F.. 225 =03I0 PROPOSAL FOR SEWAGE DISPOSAL SYSTEM REPAIR bit v O F� OWNER'S NAME JL SITE 1.=TION 7 0 Jet, MAILING DD• E. 0 70 _ffl PH60N 1 MM• a ED DAM .. • •. ED INSTALLER �f-L .4 V, Pi 0-,U- . P14 h4,, -.. & Relation; rt),.-K (i.e, owner, PHONE (clxj) 51 27, Q-. [9 - 1 -36 crh — PM Cagaaint # :rant, etc.) ® TYPE FACILITY PHONE S2 �� � % Ow,, e-, y 52:6 -37 s-� 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.. ; ,. n r 1000 G'L D 5. • = WI Proposal Proposal Disapproved AA XJ IV, Inst)ectorls Signature & Tiae _ roposal approved with the following conditions: 1. Procurement of any Town permit, if applicable. 2. Submisgion 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 canponents 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' sleep drywells 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. I, as comer, or reported agent of owner agree to the above conditions. y SIGNATURE TITLE rggS : &�,t •PATE OPIES: Vbite (PAD); YeUcw (Tam ST); Pink (Applimnk) LEE c ' N•44 °55 i i � 1 LfF°��zr�yaKN''�� �'`A\ ?�§e'YaY ��. tyf�MYs.- r�'t�n. .. _ i r.�•.�. :,:r�• ., AVENI�E E (SURVEY) 77-56 (17dD MA P)- 75. 00 _ CONONETE, NLOCN, NET' WALL bt: h v`l y N xrnp o0 6v,n�H97 %b�, 1, O — /'[= STORY, —FRAME � •` \ 17 A3 AM 0,a / 1 to A a .....E _ SION.Y FNANE —. •� � � O�Q� ? — �� ! � \Y y / S70RY' FRAME (r EMC• •' ` [J /�/ �` 0 s b n n s rs a a 0 ..y 1 + . 7 � •� \ It ► /.. a.. All \9 .00 c ., d p \�L ON so os� py 3 y to o30. C) � 41, A zo („ Vct 9vo — ei _fi ��• +o X. 5�e,' •. 00 AA 0� V� C� 0 oy _.. ?.- \. . . • ._ � :� � '� � '•. fib. .... � -. � • � 1 k ° d ❑ ❑ SITE LOCATION OWNER'S NAME MAILING ADDRESS APPLICANT cJ6 PUTNAM COUNTY HEALTH DEPARTMENT DIVISION OF ENVIRONMENTAL HEALTH SERVICES TM PAIR '_.., ..... _, . ._._.._ _.. Interr:andlse Orzl - -.- - PERIMIT.• ;��.. ' 1: Repair Permit Issued in last 5 years 13Aot in Watershed Repair within Boyd's Corners, W. Branch or Croton Falls Res. Z Delegated .sa.; Repair within 200 ft. of a watercourse or DEC - mapped wetland ❑ Joint Review TOWN TM # U�> 1 D `�' 36; �Olth �ryi�� PHONE # 25 1� . Name & Relationship (i.e., owner, tenant, contractor) DATE CC FACILITY TYPES PCHD COMPLAINT # PROPOSED INSTALLER L �nnQ,^ �' cj S ©�, (���,��_PHONE # Ja 90,0 �5 S ADDRESS fy ►-r� %y� r f��� f �L REGISTRATION /LICENSE # e 5— 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) NOTE: The Department may require submittal of proposal from licensed professional depending on the nature and extent of the repair. , r , / also 0 '09kyl I, as owner,agree to the conditions stated on this form a SIGNATURE ri TITLE DATE (owner) I, the septic in II r, agree to comLpJy with the conditions of this permit for the septic system, repair _.:jiGNAT 141E TITLE`�;�_ . DAT E (installer) Proposal approved with the following conditions: 1. Procurement of any Town Permit, if applicable. 2. Submissioritiof 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 „backfille until authorization to do so has been obtained from the Department. wr'~ INTERNAL USE ONLY i Proposal Approved ° ..: Proposal Denied ❑ In pector's Signature &Title D to Exp ation ate Repair or000sal is in compliance with applicable codes ts 0 No COPIES: PCHD; Owner; Installer PC -RP 99ML Rev. 2/07 Sheet. to ! PUTNAM COUNTY DEPARTMENT OF HEALTII D>I.VISION °OI+ ENVIRONMENTAL IIEA`I'LII SERVICES FIELD AC'T'IVITY REPORT NAME* ;1 %iV.� � TPI: Street Town State Zip PERSON IN CHARGE no MTTPR VTFUUFn: l ,5t%1✓41Z /-[ - -- Ti ,qtP: Name and Title TYPE OF FACILITY: L' -Rel ", Z FINDINGS: Signature and Title r RFPCIRT RFC FTVFn RV: I acknowledge receipt of this report: SIGNATURE: 02/96 Title: PUTNAM COUNTY HEALTH DEPARTMENT DIVI'SION:'OF"ENVIRONikN"TAL HEALTH SERVICES 4 TH dS'.IS NOTA REPAIR PERMIT PROPOSAL FOR EXPLORATION OF SEPTIC SYSTEM FAILURE All information below must be fully completed prior to any scheduling SITE LOCATION OWNER'S NAME' MAILING ADDRESS L l>� TOWN M'# r_ �S PHONE # Ge! ©- 3sS PROPOSED CONTRACTOR /INSTALLER Geo►►�LQ;',�s,[ PHONE IV Y�t ADDRESS CoJ`�-(Civ�c[�!yl�.nor ni /asl7REGISTRATION /LICENSE # /017—/, Reason for exploration: ❑ failure to surface ❑ back -up in. house ❑ findlimits of system for repair'O other (explain below) Inspector's Signature & Title FOR COUNTY USE ONLY Date. Appointment Date: Time: A9 /e7 ?'p kiy:excel:septic sos PDT .9y occn ox4 RD o Bsa b7 �0Ob9 `. VOl3N0 3 lul LU O 01. RD Qu ¢ D TEST i •, � �Y� rn ag_� ,06, - _ y bO,ki/ $ ad WAY CRO Z ^-•^� 3My �� � � , i �f• rs pPE �' �� Moil ? � - 0 k h CY J l 1.� - a > a 1 ... 4 F+✓ f 013 1sn0< . r OLUMS Cam! �Y✓al J O 7 6 u61 s i- O 1 dO dOHS Is3M ONO OY� U��a O V �=Sn0 ¢ �0d. RO', w ON Q Q l I S� a �n .RIDGE AV S �-^ EST AV W y¢ �., NTAtN � 3710N34 a RAit^- -t'� �SaM �QUS ROIL OW j Sheet of PUTNAM COUNTY DEPARTMENT OF HEALTH MNIMN OF EN.VJRON-MFN-X,,AL;HE-ATJ,-IJ.-SERV.-ICES FIELD ACTIVITY REPORT NAME: Tel: A n 1) R'F.P,,(;: Z 161E 4 &4vdw *j. /I-,-- Street Town State Zip PERSON IN CHARGE OR TNTF.RVTFVvrF.T). • Ct9AZ'ST-, 3//:3& 9 . Name and Title TYPE OF FACILITY: FINDINGS: -I)Y-/ Signature and Title RFP n1R T R RC.F.TVF.D BY., I acknowledge receipt of this report: SIGNATURE: 02/96 Title: e fir -5 4,01 :YJ4 5c ant. 4cc,.vA 34 L4, Signature and Title RFP n1R T R RC.F.TVF.D BY., I acknowledge receipt of this report: SIGNATURE: 02/96 Title: AS BUILT DRAWING At.: ^ C•. e:-: L. a.6...r.+KS_�r.....4...G.._.... �.:ac5.. .�0 .. .r.. �•.. �. �.. yam.. ..� C.'rn ..y..ri'.. ...� � .v' .s._a_ -.w err :.M •!. .was =:u �. a •. a� .it Via.. 'G-^.s. � ..-a .. Tr e pu.11 I 0004 a� +U-K 1. n V k(4-4-- A )-Z) I ex, ..—Ocg z Door Z, 2i -7 13� 70 Lee, Aj a Leonardi & Son Construction, Inc. late: 12--j 6 Carol n Dr. Z I y Cortlandt 1Vlanor 10567 (914) 736 -9010 Shect of PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIRONMENTAL NEATER. SERVICES_.., .- ......:: _ .: FIELD +ACTIVITY REPORT' , Street Town State Zip PERSON IN CHARGE Name and Title TYPE OF FACELITY : ��cr.Le �,�•��� 1 �� FINDINGS: Signature and Title RFPCIRT RF.C'.FTVF-T) BY., I acknowledge receipt of this report: SIGNATURE: 02/96 Title: Page No. of Pages LEONARDI & SON CONSTRUCTION, INC. OWNER: LOUIS LEONARDI ..6 CAROLYN:DRIVE,o-- CORTLANDT MANOR rAY.10567:::•:. (914) 736.9010 LIC. #WC- 3112 -1-190 o WC- SEPTIC LIC. #00067 o LIC. #PC -560 (CERTIFIED) PROPOSAL SUBMITTED TO PHONE DATE STREET JOB NAME CITY, STATE and ZIP CODE JOB LOCATION ARCHITECT DATE OF PLANS ` 1�o JOB PHONE \,VC We hereby submit specifications and estimates for: 11*,an / 4(9 1� Rom. . .............. . . .............................. .................................................. ......................... PLEASE NOTE: 'SYSTEM LONGEVITY IS NOT GUARANTIED UNLESS DESIGNED BY A LICENSED PROFESSIONAL ENGINEER.` 'TANK TO BE PUMPED BY OTHERS AND PAID SEPARATELY! 'NO LANDSCAPING RESTORATION, OTHER THAN GRADING DISTURBED AREAS IS INCLUDED UNLESS SPECIFICALLY STATED' We proPOSP hereby to furnish material and labor = complete in accordance with above specifications, for the sum of: ).• Payment to be made as follows: dollars ($ A FINANCE CHARGE OF 1%% PER MONTH WILL BE ADDED TO ALL All material is guaranteed to be as specified. All work to be completed in a workmanlike Authorized manner according to standard practices. Any alteration or deviation from above specifications involving extra costs will be executed only upon written orders, and will become an extra Signature charge over and above the estimate. All agreements contingent upon strikes, accidents or delays beyond our control. Owner to carry fire, tornado and other necessary insurance. Note: This proposal may be Our workers are fully covered by Workman's Compensation Insurance. withdrawn by us If not accepted within Amphince of r®p®sal —The above prices, specifications and conditions are satisfactory and are hereby accepted. You are authorized Signature to do the work as specified. Payment will be made as outlined above. Date of Acceptance: Signature days. LEE AVENVE N• 44 °55*E- (SURVEY) 77,56 / (F7LE0 MAP) 75. OFl _ S � + PO p E7 M -L ONCR fTF &LOCX ' . R' A - y o s'/ COI 44 �m o i -era - x °a L kh • ., �. ^ / =-Jlo RY: -FRAME It Nt 0 f T� -sro#r FRAN[ Lv a 410 .,. FMC.. •�, l�/ a A s A O }• 7 `9�`,ya od i a 0 �3 It 4N C) 14, ^1 . o •: w A a �0 �!•1r�' Z } 1 ��fi•$$,,/