HomeMy WebLinkAbout3089DOCUMENT CONVERSION SERVICES PROVIDED BY
IMAGING & MICROFILM ACCESS, INC.
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631- 589 -8100
62.64 -1 -7
BOX 25
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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
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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)
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PIZZELLA BROTHERS, INC
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,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-
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ORGANIZATION• .jqr- ��/� b�►,�
FAX NO.:
PHONE NO.: ,
FROM:
NAME: SAN 1' . 2"i's I I,,
MESSAGE:
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IF THERE IS A PROBLEM WITH THIS YRANSMISSION, PLEASE CALL THE TELEPHONE k LISTED.ASOVE.
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Sheet_of�_
PUTNAM COUNTY DEPARTMENT OF HEALTH
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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.
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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
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DRAWN BY:
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