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HomeMy WebLinkAbout3089DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 62.64 -1 -7 BOX 25 U SITE LOCATION OWNER'S NAME MAILING ADDRESS APPLICANT c0 4- PUTNAM COUNTY HEALTH DEPARTMENT DIVISION OF ENVIRONMENTAL HEALTH SERVICES Name & Relationship (i.e., owner, tenant, .TM# ONE # 9'410'7bi DATE 0 cl FACILITY TYPE PCHD COMPLAINT # PROPOSED INSTALLER ��`Z�rt9Grv� ins �-� �- PHONE # q14-7' q.340s ADDRESS ') 0oy W eo D MD REGISTRATION /LICENSE # 10$6 ^14 • IUC -, 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 and extent of the repair. %% !'er.e 4: i� A:f e,A 71 ,0� C,cc �ie�.n � � �c�in �n ,� A d' IIn L' Ito C. �CX J Zi ��e_ . I, as owner,agree to the conditions stated on this form SIGNATURE TITLE DATE (owner) the septic installA�,`gree t0emm ply with the conditions of this permit for the septic system repair SIGNATURE TITLE DATE S h •O� Y (installer) Proposal approved with the following conditions: t 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. Z' INTERNAL USE ONLY Proposal Approved Proposal Denied ❑ Inspector's Signature & Title Dat, Expiration Date Re air proposal is in compliance with applicable codes Yes No 0 COPIES: PCHD; Owner; Installer PC -RP 99ML Rev. 2/07 FROM :PIZZELLA BROS APR-09 -8009 A8:26Ab o' FAX NO. :9147883738 FROhKNViRONK)ITAk HEALTH Bb52 ?819ti May. 05 2009 06:14PM P1 T -535 P.001 /001 f -844 CUUNTY HEALTH DEPARTMENT DIVISION OF ENVIR.OIVMENTAL HEALTH SERVICES' THIS IS 140T A REPAIR PERMIT i�ROPw;?SAL POp �2fPL RATiOW OF 60111; � Fitt t rwrr �f IraPorr�atiott below it91 t be !! compleftd prior to Sny scheduling SITE LOCATION. 3$ UNi 0t it r} TOWN �1J�ie UAW4,6 3M # 44 OWNE9`S•NAME. e+41 ...�P40NE��ID_Ss"LCy~�75�8. MAILING ADORESS . �, u„�; a bt �► /1.�Z avy,n [>.�`tf PROPOSED CONTRACTORANSIrAL1 ri _Eiz �y ytori 0.�` w PHONE,*�ra• ADDRESS . �DQu 4ID,A o!+j1e44E REGISTRATION /LICcN9E j0 40 Rte ,Psr �>9Pl W fallWO to 6tdtfte9 0 132 up In house 0 find Uftta of xystefn for repair 0 othdr (explain belgw) f :: :. _ ..: .. ti - _ -_ .. - -. . — - .. -. •_ _� a ..._ .ou.a -�-- . _ . _,.mot - —�..t .. - ow I •� Amoirnmem Date: ery: ®xe�i =aeAtic Owe � P P PIZZELLA BROTHERS, INC ADIR ,CORTLANDTQMANOR, NY 10567 PHONE: (914) 739 -3405 / FAX: (914) 788 -3738 FAX COVER SHEET DATE: -`S . d TOTAL## OF PAGES INCLUDING COVER SHEET: PLEASE DELIVER THE FOLLOWING TO: NAME: (7 GO L- ' ORGANIZATION• .jqr- ��/� b�►,� FAX NO.: PHONE NO.: , FROM: NAME: SAN 1' . 2"i's I I,, MESSAGE: r Qt, &S fvv 7- A4,p IF THERE IS A PROBLEM WITH THIS YRANSMISSION, PLEASE CALL THE TELEPHONE k LISTED.ASOVE. Ed WdbT:90 600E S0 'h ?W 82ZZ882 -06: 'ON Xdd SOda d-1-18ZZ I d : WOdJ \ a Sheet_of�_ PUTNAM COUNTY DEPARTMENT OF HEALTH ., -.4 • DIvrc .gOlv_Or._FN�I.R.CrIMFst�T�v �$EA�r.�r,cED.vlc�as -: .. .�. - - ..__ .. . _ - .. FIELD ACTIVITY REPORT1 NAME- 571F,44PL F—W TPi• eTMRRCC' yA71DII,LA Y46W OetAOW L/ /LV—y Street Town State. Zip. PERSON IN CHARGE nU TNT-F'R VTFwFTI• P1zz- &L(,I$ l3�QTift t l�atP Name and Title TYPE OF FACILITY: FINDINGS: 02/96 Title; R P-17. — r.4 � _ : T'^ ... rte .hR =` a4vaaYiv -JF+ ?� ���• >t,�'L'�<.eFY•e.... ,V^. � •;. :,� ..�., V . •tom_+.'• . ... PUTNAM COUNTY DEPARTMENT .OF HEALTH DIVISION OF ENVIRONMENTAL HEALTH SERVICES DESIGN DATA SHEET -SUBSURFACE, SEWAGE TREATMENT SYSTEM. Owner: rjT 6w- P Address: 39 b 1 LL t4 seta Located at (street): TM # Section: i Block - 'Lot Municipality: Py7NAM 1%t,_r_V Watershed: vT x � ?ZIIJ�T SOIL PERCOLATION TEST DATA Witnessed by: Date of Pre- soaking: Date of Percolation Test: Hole No. Run No. Time Start — Stop Elapse Time - (min.) - Depth to. water from ground surface (inches) Start,- Stop Water level drop in inches Percolation Rate min /inch 1 2 3 5 1 2 3 4 5 2 r 3 4 5 1 2 3 4' 5 Notes: 1. Tests to be repeated at same depth until approximately equal percolation rates are obtained at each percolation test hole. (i.e., <J min for 1 -30 min/inch, < 2 min for 31 =60 min /inch). All data to be submitted for review. 2: Depth measurements to be made from top of hole. Form DD -97, pg I of 2 ' Y . DRAWING NUMBER: �j F� ins i 'Er i - - 6. 2, t Ti "P4 A 1�b I& Lail e1i LIC.# WC- 4149 -H91 PIZZELLA BROTHERS, INC. UC.NPC -192 at SCALE: a APPROVED BY: DRAWN BY: 5 DATE: ' ® REVISED: DRAWING NUMBER: �j fiauSG CAYUGA e, IM 41 l 51.06 mi :x3.96 fs : . 59 0 � J % r/, �RPN �qa �y .50 so 6