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Home My WebLink About3302DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 73.05 -1 -20 BOX 27 1 rm -a I r 1' rim ` Jr I' ' IN I ♦ f .L LF 03302 PUTNAM COUNTY HEALTH DEPARTMENT DIVISION OF ENVIRONMENTAL HEALTH SERVICES _ P_ ROPOSAL_FOR SEWA u YES No Internal Use Only PERMIT # 1� 1 ❑ ly Repair Permit issued in last 5 years ❑ Wot in Watershed ❑ Repair within Boyd's Corners, W. Branch or Croton Falls Res. Iff Delegated ❑ Repair within 200 ft. of a watercourse or DEC - mapped wetland ❑ Joint Review SITE LOCATION TOWN TM # 9 3, 9_ 1 �; 0 OWNER'S NAME p,� 0 C . HONE # MAILING ADDRESS `3 Siprvice "US �v�,fc (/w," )' y l Dd-? 9 APPLICANT IL -pt-, P_S �`� y r" i J e-r 1 Cd 1 f ry "f r Name & Relationship (i.e., owner, tenant, contractor) ti DATE /l 12 L D5 FACILITY TYPE PCHD COMPLAINT # PROPOSED INSTALLER C4 � T- PHONE # �1 �Y 0 �e 3 VV Cicrq ��i Cr>' ADDRESS 3 q Ca ly v a VC- -PO„ REGISTRATION /LICENSE # 1 C Pro osal (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. I, as owner,agree to conditions stated on this form SIGNATURE 1 TITLE DATE 116 A (owner) the i f septic_lnstaller, agree to.comply.with the - conditions of this permit fgr,.the septic system repair n - -_� - •- -.• -- SIGNATURE TITLE DATE ? 0 / (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. wwre�w w nr r.eu � in 1 Cntl_ML UOr. V111.T Proposal Approved Proposal Denied ❑ ® c In ector's Signature Title Da a Expiration Date ,Repair proposal is in compliance with applicable codes Yes �'. No ❑ COPIES: PCHD; Owner; Installer PC -RP 99ML Rev. 2/07 „ PUTNAM COUNTY HEALTH DEPARTMENT DIVISION OF ENVIRONMENTAL HEALTH SERVICES,,. l PROPOSAL FOR SEWAGE TREATMENT SYSTEM REPAIR YES NO Internal Use Only PERMIT # ❑ ,f� Repair Permit issued in last 5 years ❑/, Ibt in Watershed ❑ ED Repair within Boyd's Corners,. W. Branch or Croton Falls Res. O Delegated ❑ _ L Repair within 200 ft. of a watercourse or DEC- mapped wetland ❑ Joint Review SITE LOCATION .�+ (I ��g� TOWN E Utr�� C�5 r/t✓c TM # 9 S° OWNER'S NAME �'�,�l, ��,.�7"� Cyr w PHONE# , MAILING ADDRESS -`'fit �rc.�_ kn�il>� lvi, i`� (✓4 �/� 1� �'' / y.t ~ �l APPLICANT t vu r s t^� � i� r` e C't� - Iv r Name & Relationship (i.e., owner, tenant, contractor) DATE ( % *2 f D FACILITY,TYPE _ _ PC_HD COMPLAINT_# _ PROPOSED. INSTALLER v u t ff c, ; ti `' PHONE # 5/Y -2 G 0 4 3 VV ADDRESS C/ C a G? VC. PV, REGISTRATION /LICENSE # ( '% t 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. j ,n "]` C.11� �Gt �Cin, lt. 2 J V' ` Ca-,-,c f I, as owner,agree to t e conditions stated on this form SIGNATURE TITLE DATE r�A/ (owner) I,. the.. septic. installer,. agree- to,comply with the conditions of.this permit for the septic system repair '.s` t SIGNATURE ' �.- --'d` ;y TITLE /r'. DATE, ✓ 7 JO r` (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 repaik#ll function. 5. No completed work is to -be backfilled until authorization to do so has been obtained from the Department. 1111 1 QHNAL USE ONO Proposal Approved .=.r, ` V Proposal Denied ❑ f' 7 le, Ins ector's Signature & Title,. -.`- ° "A t Date Expiration-Date,' + ,Repair proposal is in compliance with applicablexodes Yes ,B; No 0 COPIES: PCHD; Owner; Installer.. PC -RP 99ML Rev. 2/07 A, R --CO STRUCTION.--C-DR-PORAT 1. N 34 Columbus Ave Putnim Valley N.Y. 10579 914-76V 6344 Anthony Toteda, TM 73.5 1 20 Date 6/17/09 73 Spruce Knolls v License# 1137 Putnam Valley N.Y. 10579 Septic repair A 1 16.0 B 1 28.0 A2 24.0 B2 35.6 Replaced tank with 1250 gallon concrete tank*. Replaced #1- b4oK. — -------- —,— : '13. 3rc�C,— i ::i::`:, :_ <: ^?l24°.�XS'i'S::aR.Tl• ^�snxaceGta�'�rars4tixacax -m• �ec�•..,cac:sa.n� +raslx -ru. sacs ,:..aea..»cresmn,a.<r::an.•:. - `, 0 E SURVEYED & PREPARED BY BUNNEY ASSOCIATES ENGINEERS & SURVEYORS 156 KATONAH AVE. KATONAH. NEW YORK A01 s A �r 0ca7 LOT Ar.EA= 4q,1gq °� i� 'CA[ � Z. osc se- LOT N-2 :3 65 Ile A ,ayse fie'( ?l oq " a 4? � At-c- rE', t -' APL 3 40 Q Q73� 0 E SURVEYED & PREPARED BY BUNNEY ASSOCIATES ENGINEERS & SURVEYORS 156 KATONAH AVE. KATONAH. NEW YORK A01 s A �r 0ca7 C� « � ij {E�s( vl JfY C�