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HomeMy WebLinkAbout3196DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 72.19 -1 -6 BOX 26 ! .. .; J 1.� f I L ..r = f - ir jL 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 ui��9s o 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� IF Ile- A.-- iNS! I11eeQ dt- dfl./ WIfJ/ �ea,r toerF- 1,ec er vtckA e % / O l SwJUC4vfG " OJr[.r , ._.�__ ..:. _ . .. �. -.. w...__ ._/dim r�— �;��%� � �r���l� "... � "�:.a��a��u,.�Po �`,�._._::._ ._ . _--- •-- .._.._.__._._ _._., _ -�.�._ _ Signature and Title RFPIIRT RF.0 F.TVFT) BY: I acknowledge receipt of this report: SIGNATURE: 02/96 Title: RPM'.