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62.18 -1 -73.2
BOX 25
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03041
PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
YES NO Internal Use Only PERMIT # �\ -a i�- Q
❑ Repair Permit issued in last 5 years ❑ of in Watershed
❑ . Repair within Boyd's Comers, W. Branch or Croton Falls Res. Y Delegated
❑ ❑ Repair within 400 ft. of a watercourse or DEC - mapped wetland ❑ Joint Review
Scawwaa f ` � V
SITE LOCATION S l(�ruc.e_ 1� i� .h TOWN puT►�,�. �iw b�Gc� TM # 1 3.
OWNER'S NAME °`W\ M� lC't -�. PHONE461-� 5 C) 3a
MAILING ADDRESS 1--tV (7JZ4E7V)Q ' AJ0tna ,\ \eQ(,( (&•1 I()`- (`I
APPLICANT I :M G u a ti; ex i
/ Name & Relationship (i.e., owner, tenant, contractor)
DATE S I FACILITY TYPE PCHD COMPLAINT #
PROPOSED INSTALLER j l h Uti L` -i e � PHONE # ]) `f - %� O Ct 3 T y
ADDRESS ? i ` REGISTRATION /LICENSE # 4 3
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. j
R C'_ 0 ��c e +a r► IZ �.c� ��� � Up o r7,
i
I, as ownetagret3 to th conditio stated on this form
1
SIGNATURE TITLE � DATE V
(owner)
I, the septic install , agree to comply with the conditions of this permit for the septic system repair
SIGNATURE w TITLE J9 1r.9 DATE .S 3 (,
(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.
INTERNAL USE ONLY
Proposal Approved Proposal Denied ❑
Its 3' a
Irnspector's Signature & Title Da a Expiration Date
Re air proposal is in compliance with applicable codes Yes No 0
COPIES: PCHD; Owner; Installer
PC -RP 99ML Rev. 2/07
(;uxLTiERr".nicO-NsTRucTlOr4"�cc)IZPORATTON"-
34 Columbus Ave Putnam Valley N.Y. 10579 914-760 6344
Bridgette Bacon T 62.18-1-73.2
Oscawana Lake road
Putnam Valley N.Y. 10579
Replace tank with 1000 gallon H2O concrete tank
A 1 6.0 B 1 12.6
RI)
4-6
0
A
Date 5/12/09
License 1# 1137
......... ..
PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
ernalt. _a ' PEAMrr #
❑ ❑ Repair. Permit issued in last 5 ygars �/Delegatqd
Not in Watershed
11 Repair within 'Boyd Comers, W: Branch or Croton Fags Res.
-'❑ ❑ Repair within oo 8. of a watercourse or DEC - mapped wetland ❑ Joint Review
SITE:LOCATION �� �r-U« 1�;�k�, +lake TOWN #
OWNER'S NAME . fr�_��..;..;. ; ..t ¢.t PHONE 1
MAILING ADDRESS
APPLICANT I rn. Go, !+
Name & Relationship (i.e., owner, tenant, contractor)
DATE��' �� FACILITY TYPE PCHD COMPLAINT #
PROPOSEDtINSTALLER .: + PHONE 6-... J �G C��*
ADDRESS 4' ��_ �(.�'1�'Y�7y� �� ✓r`� ��rl ��GY. �- M �� REGISTRATION /LICENSE # J f , f7-
Proposal (include a separate sketch locating the house, property fines, all adjacent wells within 200
feet of repair and the•Jocation 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"t F
Proposal Approved
Inspector's Signature &
is in
INTERNAL USE ONLY
Proposal Denied
ipe with applicable codes
COPIES: PCHD; Owner; Installer.
PC -RP 99ML
0
2 /' ,,,
Date
Yes
NDiration Date
No O
Rev. 2/07
'
--_
I, as owner,agree,• to the conditions. stated on :this form
'
SIGNATUREI : ; �\' �..:,��� �. TITLE . ` �J �." „` �1 , ... DATE
-
,,
-- i; tt�ep� c irises agree 1v mply:wiih-the corti R d6§-of this�erm,itI- or:iiie septic•5ysti" m,, epair— -
-. - ___.._.... --
,. V , ,
TITLE r`:f DATE
-_�...
SIGNATURE
(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., 125q''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 ft design and there is no guarantee to the duration at whigh 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..
Proposal Approved
Inspector's Signature &
is in
INTERNAL USE ONLY
Proposal Denied
ipe with applicable codes
COPIES: PCHD; Owner; Installer.
PC -RP 99ML
0
2 /' ,,,
Date
Yes
NDiration Date
No O
Rev. 2/07
MEMORY TRA111SMI SS ION REPORT
w, t:r fr .... ..r -,-v.� ..- ...., -- • .. •e-» -sr ,..c - .�4.•, ...». -.�oa - <- .,Vn4_n,- .a..�, q... e.m- ... -. :. :.- ... .. -.. . rr•,v., :, �......,r...,.. :s,aMT'...wr. -. g.ar+. : :..o�. c-.mao..w.,•µn
TIME MAY -06 -2009 03:53PM. .
TEL NUMBER 8452787921
NAME ENVIRONMENTAL HEALTH
FILE NUMBER
DATE
TO
DOCUMENT PAGES
START TIME
END TIME
SENT PAGES
STATUS
{
FILE NUMBER 934
: 9.34
MAY -06 03:52PM
95268806
001
: MAY -06 03:52PM
: MAY -06 03:53PM
001
: OK
** SUCCESSFUL TX NOT ICE * **
PUTNAM COUNTY Ha^L- -rH 0EPARTMEN-r b °
OIVIS10N OF ENVIRONMENTAL HEALTH SERVICES LD
PF%OIPG�SAL FO�t S bbAf�E TErtE6�TiNAE®�Il� SVS -T-gm II%EiPAiR
O intorrtal Use 0'"IX pIRRILg V ff
Repair p m
erh 1s oa In last 3 years ' ' Ot in Watershed
• Repair wMnln aoy wa Comers. W. Branch or Croton PBUs Ras_ O @legated
SITE LOCATION . S �ruc+L �` �i ^ e TOWN Z�. Vcjjg- � TM #
OWNER'S NAME VHONE V
MAILING AOCRESS l
APPLICANT d i
J Nac e & Ralatlonship (i.e.. owner, tenant, contractor)
• DATE _ S 1 3 'O ` FACILITY TYPE v PCI-10 COMI�LAINT a
.. -.> . .. IN3-El L..i -EP —RI C:iNF # a -.F. `ice'. �� r�. fi. �rl„ -•-� / �/
ADORESS �/ CO�uA -r�z/s i� ✓�1'�� +vii I< <7 REQISTRATION. /LICENSE # L L _3
Proposal (inciudie a sapmrate sketch locating the house, pr/aperty lines, ali a0tacant w431023 within 200
fact of repair and the location of esdsting 9MCA propoaedi ayst0vn) .
NOTE: The Mepartment may require submittal of proposal from licensed professional depending on the
nature and extant of the repair.
� K 77hx 1t (�� �'+� 1 V O t7 Ci4. 012—
1. as. owner;,sg to th conditio stated on this form '
SIQNATURE TITLE _ DATE
(owner) .
1, the septic install agree to comply with the conditions of this permit for the septic system mp^air % Q
SIGNATUR E!y -/ cC GATE
(installer)
a;oorovad with the lollowino cores Hlons: +
f _ Pracuramant of any Town Parmlt, if npplicobla.
2. submiselon of as built repair sketch by the septic system Instailer within 30 days of the repair, In duplicate showing:
a. Owner's names, Sita Street Name, Town and Tax Map number
b. Locatfon of installed components tied to two fixed points
o. Systenf description (s. g.,. 22SO gal- COnareta septlC tank, etc.)
d. Installers' name and phono number
3. oyatom repair to ba performed in accordance with the above proposal and aonditlens
4. -rho proposed SSTS repair is considarod a best fit design and there Is no guarantee to tree duration at which the,
complated SETS repair will lunation.
S. No completed work Is to ba backfilled until autnorizatrort to 0o so nas been act- naa from tno 1 aparur.® L
/- IINSERINAL. USE OPILV
Proposal Approved Q- Proposal Oeryled -
nspector's Signature 1� 7'i Q8 a � Expiration Oate 1
FtCPalr propioo tl la In mn-n P11 --aO with mppllCaola uU0as Yes .f NO d
COPIES: PCHo; Owner, Installer
PC -RP 99ML _ Rev. 2/07