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BOX 26
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03196
PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES /.<J
YES NCf Internal Use Only PERMIT # T1" 1
❑ Repair Permit issued in last 5 years eDelegated
of in Watershed
d❑ Repair within Boyd's Comers, W. Branch or Croton Falls Res.
❑ Repair within 200 ft. of a watercourse or DEC - mapped wetland ❑ Joint Review
SITE LOCATION 5 �►+� 1.5 6z TOWN RVrP 0A V.}'<<'�yTM # o?• /�` /— �'
OWNER'S NAME S AWA 'Tb (i-_9— PHONE # 137. °�® Z1"l L
MAILING ADDRESS ' Lug 6�ic' A -0 62f 7f
APPLICANT Wf 70 iz
Name & Relationship (i.e., owner, tenant, con tra r)
DATE FACILITY TYPE ��S� '' ��A� � PCHD COMPLAINT #
PROPOSED INSTALLER Cs{� SWV;C "�I 1004— PHONE # C�' / -4 731'"
ADDRESS jig" �� `� REGISTRATION /LICENSE # 10 13
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.
L .^-' 2 Py 7-1 A) c- 0 A-4 , AJ 7y
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0
I, as owner,agre to the conditions statel on this form
SIGNATURE C 0 TITLE j,.at- 60,0L DATE
(owner).
.�. ._....�.. I ., ♦;+,y ''t.- • 11�,.. ,,a�a -__.. �..,...n I ..�:a4.'t� `I °'tr8'3��u.. L 13cauol , v i G t;' i, rvmp �, I le condiF7J fo ai I this
p- ..r• � p "
SIGNATURE TITLE DATE aj Z
(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 ❑
Inspector's Signature & Title Date Expiration Date
is in compliance with applicable codes Yes ❑ No ❑
COPIES: PCHD; Owner; Installer
PC -RP 99ML Rev. 2/07
SHERLITA AMLER, MD, MS, FAAP
Commissioner of Health
LORETTA MOLINARI, RN, MSN
Associate Commissioner of Health
ROBERT J. BONDI
County . Executive
ROBERT MORRIS, PE
Director, of Errvirorimental Health
DEPARTMENT OF HEALTH
I Geneva Road. Brewster, New York 10509
May .19, 2009
Vito Salvatore
653 Sprout Brook Road
Putnam Valley, NY 10579
Re: Septic System Repair at
653 Sprout Brook Road
(T) Putnam Valley, TM # 7119=1 -6
Dear Mr. Salvatore:
Per our conversation on May 14, 2009. in reference to the Official Notice of Non - Compliance
dated May 6, 2009 the following information is provided.
This Department is requesting your assistance in this matter by means of an acknowledgment
letter from you stating the name of the company that performed your septic system repair along
with the date of said repair, and the type of work that was performed. The letter will also need to
state that the work was performed at the above referenced address.
Also. as . discussed, you as the legal owner of the. above property are responsible for the filing of
tic -r -hired rm aii -pc-e iii (eiicloseu acid the subnilssion •of. the septic S steffi as -built idn' o.f
� � l� w- --_ - � 1 P Y ' �P
which this Department can assist you in producing.
Again it Js sincerely hoped that further action will not be necessary and that you will cooperate by
providing the above noted information.
If you have any further questions, please contact me at 845 -278 -6130 ext. 2261.
Sincerely,
Gene D. Reed
Sr. Environmental Health Engineering Aide
GDR:kly
cc: B. Siniscalchi Paving, Inc.
Environmental Health (845) 278 =6130 Fax (845) 278 -7921
Water Supply Section (845) 225 -5186 Fax (845) 225 -5418
Nursing Services (845) 278 -6558 Fax (845) 278 -6026
Nursing Home Care Fax (845) 278 -6085. WIC (845) 278 -6678
Early Intervention / Preschool (845) 228 -2847 Fax (845) 225 -1580
Sheet of
PUTNAM COUNTY DEPARTMENT OF HEALTH
77 r 7 T t ♦ _ _ _ . _ -_
FIELD ACTIVITY REPORT
NAME: Tel.
ADDRESS: 7(0/46 &MA0
Street Town State Zip
PERSON IN CHARGE
OR TNTFRVTRWFT) : /j�GViU/ SIA)l 4tc,r�/ T)ata C�3o %9
Name and Title
TYPE OF FACILITY: . —Izf, S�,j�
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Signature and Title
RFPIIRT RF.0 F.TVFT) BY:
I acknowledge receipt of this report: SIGNATURE:
02/96 Title:
RPM'.