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HomeMy WebLinkAbout3102DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631 - 589 -8100 62.71 -1 -13 BOX 25 03102 PUTNAM COUNTY HEALTH DEPARTMENT DIVISION OF ENVIRONMENTAL HEALTH SERVICES wae.. ..sr .T.a-,rpe� ��uo --�R. `: - +r.�v�� r. - ri.�.s'� -mca� :. �c -r .. •"".a. .� �. w ,:•e'�••.tV V �••� � rV • �:� • •�•- �_ -•w.0 `vaF.r.su..w �- ^yc+ul, .r• +w..^..�,+•j. �. •�.: v� .v :w Jr. � �.. ter.• � PROPOSAL FOR SEWAGE DISPOSAL SYSTEM REPAIR OFFICIAL USE ONLY Z,3 1-0�� . SITE LOCATION % � MW NlC,,9 `✓ i TM# OWNER'S NAME 6914,k 6- doANa 'TPyhV NO PHONE MAILING ADDRESS 'p, —t—t4P iz v V4 L La v" M IL / o PERSON INTERVIEWED PCHD Complaint # ---Name & Relationship i.e., owner, tenant, etc. DATE '�C%�Q TYPE FACILITY PROPOSED INSTALLER ecyy PHONE m s CA- ADDRES S REGISTRATION# 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. _ h1, °S7'e 1%.t6 11 LZ LA ' .p� _.'T, s'IS 1�?K?E°T .ro:7 er,40r1rt—e.-.d e!nt nt 6 Fin r; r -, t6, The cent d1ii ns:st'at` d oP, th SIGNATURE TITLE �' �~ DA._-: Proposal annroved with the following conditions: 1. Procurement of any Town permit, if applicable. 2. Submission 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 components tied to two fixed points (e.g.,house comers). d. System description (e.g., 1250 gal. Concrete septic tank, three precast 6' diam. X G deep e. Installers' name and number. 3. System repair to be performed in accordance with the above proposal and conditions. Propos a roved Inspector's Signature & Title DATE COPIES: White (PCHD); Yellow (Town BI); Pink (applicant) PC -RP 99NE PUTNAM COUNTY HEALTH DEPARTMENT VIZ DIVISION Of ENVIRONMENTAL HEALTH SERVICES .7 77 PROPOSAL FOR SEWAGE DISPOSAL OFFICLAL USE ONLY AID 4_ ( , SITE LOCATION 'S AH W t- "71 OWNER'S NAME egiriv, *Q0wNvt PHONE 8''S" :4,( MAILINGADDRESS 0. DATE ail TYPE FACILITY � - ._1 4 �_.a S. ­4ROPOSED INSTALLER �AaA.,V,+q) rof�e,�& 4 4,'r, PHONE 1- ADDRESS REGISTRATION# :4 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. 'T k I f: L j) 1 C LLJC� 1-o -as-G1VVr1ei_.1 (A-repuf lid�k� of-owilef aj�eeF to eohcHtifts stated Oiftifis lorm. N SIGNATURE� .. % DATE Pro.posal approved with the following conditions: rocure 'P ment bfao' nit, ,if applicable pphcable,, M'dupi 2. Submission of as built repair sketch duplicate. -showing: a. Owner's name b. Site Street Name, Town and Tax Map number. C. Location of installed components tied to two fixed points (e.g.;house corners). d. System description (e.g., 1250 gal. Concrete septic tank, threep'recast 6'diam. X Gdeep e. Installers' name and number. 3. System repair, to be performed in accordance with the above proposal and conditions. ..iPropos 4pproved 11., Inspector's Signature &Title.. COPIES: White (PCHD); Yellow (Town BI); Pink (applicant) PC-RP 99MI 16X-TE N." HOWARD GRAGERT f-C 13 296 OSiCAWANIA LAKE RD Z3 PUTNAM VALLEY NY 10579-2000 (ZF Z7 ).Pt 'g. --r.4 ey o 14 o 4L/ '( 'I) F- a 0A, I I j LA) by M OLKR- Ca4' CAW) som ect ke CL c� �,VCA covwz ­60 A L,, %A e&k( Wit` ti LN C_ V(k 0 C, 1,f7 &—I vL­ r)_L C-0 "015 C( v* 4 em vvk J 0 vz- V_ Co -ci- M, <. 1p 4&C4. X, O. 0 X. 7 Area 999 Sq. Ft. �i l `f S � Z -) �r�OD 77- Nw is crfitmd only to: JOHN rUROCI 1.1,*M C MROCI 51eLfY CORPORAT ION COMMONWEALTH LAND rlrLE INSURANCE CO for inot, rille fiff 0644944P BADEY 8 WATSON Skrmyov a Engineering, PC. U. S. Roof 9 Cold Sa"m , NY 10516 (9141 265 -9217 Nolen I. /+livvttoft of Ms docam'mit, except by a licensed Land 51,;-yar, is illegal. I 2. All certificallons are &�Ild fm this =0 and copies ti,dreaf only if said ONX.: or tooter AM, the e.Awed ", of the surveyor -Ar.w "goat.- amocom hereon. 5 141cfwgravad ImprovemerfT , easements ar encrocclallots, If 7 , are rat shorn imfew. 4. r,f41 Promises shown Avon is /Of NJ? 97 as Stoffn a7 'hot certain moo er I.-Wod 'M..;if1vd Map NO 2 of Abelo Part ... p " m. ch was filed /A the Putire, C.71fify Clenti Office ,,. August 25, 1926 as l"Ife, Map NO ea. k .It 01,,X. t J11 SURVEY OF PRqP��rY MIFIRAREP IW- _`%Zt"�_ JOHN e LIMA F-��,,T-ZIROCI SITUAM IN THE N OF PUMAP C011N7 NEW YORK SCALE /in. =20 ft JUNE lgff� We A"ty cwWfy tjW the sm-d3, shorn hereon Nm 00-pieted by as on Jame /1 1988 1 Mot 'his Map vas camp /~ m 15 , 1.988, mw Ither this survey t,=. wepo"d in accordance wih fne existing Code of pkactive for Low Skrms as aeopree by The Ar. Yc,* smarr Association of Professional Land Stavoyps, Inc. ' A OADEY a WAMON SURVEYING a rNSINEOMS'P.C. 4 45066 by 02 No IVIF. MRW 611A L �A C7)r0 LAND. SURVEYOR "C"VSr SIF No 458651