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Home My WebLink About3145DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 63. -4 -41 BOX 25 03145 PUTNAM COUNTY HEALTH DEPARTMENT lS/ DIVISION OF'a` ENVIRONMENTAL HEALTH SERVICES.�l PROPOSAL •c -c• •+a^:• a• _: -• K!' •t _ WO.c-^�e� •.r^aan. .a w.:.... .- ... . . ai T'. ' :.`i �..n. yr w.....+n• v.... .:1•wt......' SEWAGE DISPOSAL SYSTEM REPAIR 9/y- 3f - /bp�. CWNER'S NAME J��n l,`j !1.�1u -1--e, PHONE 9i� &a8' & k a SITE LOCATION' X10 WOC-d 5+. , CYY�� I�obC1 C Iy o U , 1(��i�/1 7M# (�3. `/— 41_ FILING ADDRESS H r Cc—i- PERSON INTERVIEW c 2 ` I0g �C gpiaint Name & Relationship i.e, oaner,tenant, etc.) DATE —% — TYPE FACILITY l'eS /denizal homes PROPOSED TAWXz F'.R G PHONE t/c/, 36 — 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 fran licensed professional engineer or registered architect. y-�-; -Y A)pw 1000 6 a l f o h 51000 c�+�� 1 N I' i _ ��a� roved with the following conditions with the following conditions: 1. Procurement of any Town permit, Procurement of any Town permit, if� cable. 2. Submission of as built repair sketch in duplicate showing: a. Owner's name. b..Site Street Name, Town and Tax Map number. C.Ilocation of installed components tied to two fixed points (e.g.,house corners). .:d. System description (e.g., 1250 gal. concrete septic tank, three precast-61 diam. x 6' deep, 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 owner, or reported gent of owner agree to the above conditions. SIGN kTURE owner, . TITLE GATE I I TES: *dte (PCID); Yellow (An EI); Pink (Appliamt) PC -RP 97 ragomu ` m ,ages LEONARDI & SON, CONSTRUCTION, INC.. PROPOSAL SUBMITTED TO PHONE DATE do a STREE� JOB NAME CITY, STATE ZIP CODE JOB LOCATION Cacr 77�j ARCHITECT DATE OF PLANS JOBPHONE We hereby submit ecific.Mlons and estimates for: SIA W5 62-9, PdrLk- Ulf Proppor .hereby to furnish material and-labor— complete in accordance with above specifications,- forthe surn of:. dollars Payment to be made as follows: A FINANCE CHARGE OF I lb% PER M . ONTH WILL BE ADDE bTO ALL LIN PAID BALANCES. All material is guaranteed to be as specified. All work to be completed in aworkmanlike manner according to stan.dar . d practices. Any alteration or deviation frbmiabove specifications Authorized 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. 6wher,to carry fire, tornado and other necessary insurance. Our Note: This.proposal maybe ------.�—,—'—_�.--_---_-_—�—_�--- ' ' SIGNATURE . conditions are satisfactory and ,ovomaomvna� muome | work ass.pecified. Payment will be made as o utlined-above. j TURE , a� LEONARDII& SON CONSTRUCTION, INC. Uj NU I J AN GRADING DISTURBED AREAS. IS INCL - DED ON' LE S SR i I Y S TV-D.- r Prvpiner hereby to furnish material andlabo�— complete in accordance with above specificatibr is forthesum.of�: . dollars Payment fo'be made as follows: a FINANCE OHARGE OF 1Ih:% PER MONTH WILL BE ADDED TO ALL UNPAID SA ;e• t E �C.. S CUSIONFR I P"' SI I r p A! i F—!:f- ; All material- is guaranteed to be as specified. All work to be completed in a. workmanlike manner according to standard practices. Any alteration or deviation from above specifications Authorized involving extra costs will be executed.only upon written orders, and wilf 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. Our - Note: This proposal may be' • . workers are fully covered by Workmen's Compensation insurance. withdrawn by us If not accepted within days. r SIGNATURE ' • ' &cepfillure of f roposal —The above prices,' specifications and conditions are satisfactory and are hereby accepted..You are authorized to do the work as specified. Payment will be made as outlined above. DATE OF ACCEPTANCE: SIGNATURE FORM 65103- RAPIDEORMS IN nAORS-9449 i • Sono ^• _ fropowd Page No. of Pages • 6 CAROLYiV DRIVE ®CORTLANDT {biAi�10R, IVY 1 U567 k' � `,,�4 7 7 LIC. # V11C- 3112 -H90`a LIC. #PC -5fi0 PROPOSAL SUBMITTED TO PHONE C��%�� DATE !1 /� ,a� �a�4, ^, / .•,! "� i:,�li.Fr �f3F5': I'L`C� �� ca. .1�, �j c STREET, `y'1/� Na f 1•�`` y 'JOB NAME ' CITY, STATE A D ZIP CODE _ ' JOB LOCATION . � C�.�o�C V1•i/. 1 r✓��i � �. ARCHITECT ! DATE OF PLANS. "' JOB PHONE We hereby submit specifications and estimates for:. . S � • ' � 's PUTNAM COUNTY DEPARTMENT OF HEALTH DIVISION OF ENVIR0NMENTAL HEALTH SERVICES INITIAL INDIVUDAL ADDITION/REPAIR FORM SECTION A: GENERAL INFORMATION ,p - .. Name of Project (T)(V) 1 V TM# Year of Construction Size of Parcel SECTION 'B. TOPOGRAPHY (Please check all appropriate boxes) 1. ❑Hilly ' ❑Rolling ❑Steep Slope ❑Gentle Slope at 2. ❑Evidence of wetland Clow area subject to flooding ❑Bodies of water 13D. Drainage ditches ❑Rock outcrop 3. Property lines evident? ❑ _ Aw" 4. 'Water courses exist on, or adjacent to parcel: U �--� 5. Existing individual wells within 200ft of the existing SSTS? ❑ ❑ SECTION C. EXISTING SUBSURFACE SEWAGE TREATMENT SYSTEM(SSTS) 1. Physical character of existing SSTS area. A. ❑Level ❑Gentle Slope ❑Steep slope B. ❑Well drained [Moderately well drained ❑Somewhat poorly drained ❑Poorly drained C. Area available for SSTS. (Primary & Reserve) ❑Extremely limited ❑Somewhat limited ❑Adequate ft x -ft D. INSPECTION Date Y/p Inspector Leo exidence of failure ®Evidence of failure ®Evidence of seasonal failure �I N r n U�r HOUSE U G� V C, (1) Indicate location of SSTS A. Size and type of septic tank gallons ❑ 11 Concrete Plastic B. Type of absorption area 1. Fields ft. 2. Pits 3. Gallies ft. (2) Indicate setbacks, front street, backyard, and side yard dimensions (3) Show location of well (4) Show location of driveway (5) Note physical features (steep slopes, rock outcrops, streams /wetlands) 'i . .1 a, SECTION E. EXISTING WATER SUPPLY Opws' 0Shared well LOIndividual well L"IDrilled Dug OCasing above ground COi Qv ENTS : N • LJu ocQ S tk,r / o sr�, �y REPAIRS ONLY: Status: As Built Inspection Required: As Built Submitted: As Built Inspection Done: Inspector: I i I SECTION E. EXISTING WATER SUPPLY Opws' 0Shared well LOIndividual well L"IDrilled Dug OCasing above ground COi Qv ENTS : N • LJu ocQ S tk,r / o sr�, �y REPAIRS ONLY: Status: As Built Inspection Required: As Built Submitted: As Built Inspection Done: Inspector: