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PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
PROPOSAL FOR SEWAGE TREATMENT SYSTEM REPAIR
SITE LOCATION
OWNER'S NAME
MAILING ADDRESS
InTernawse Onl_ _ : ERERMIT
Repair Permit.issued in last 5 years ❑ Not n Watershed
Repair wMn Boyd's Comers, W. Branch or Croton Falls Res. ❑ Dele gated
Repair within 200 ft. of a watercourse or DEC - mapped wetland ❑ Join Review
'331 OSCa:O-4 -0- `A-eTOWN Pi0oicn Va I64 TM #
rr
c � rY1 an S +e r1 8 PHONE # `d45 - f5a TS - 3�50�'j
` 19
APPLICANT fbwcsioo Cca Jc� ki 4ra CAO r-
Name & Relationship (i.e., owner, t pant, contractor)
DATE - I"',5- 09 FACILITY TYPE 5' r%IC � r- Iu PCHDCOMPLkINT#
PROPOSED INSTALLER p�,� - -; ry,,,�� 1 Xc� tam PHONE # $- -- M
ADDRESS 3 �� � �,� _ C aC -Ci,S n REGISTRATION /LICENSE #
a a
Proposal (include a separate sketch locating the house, property lines, all adjacent well
within 200
feet of repair and the location of existing and proposed system)
NOTE: The Department may require submittal of proposal from licensed pr ess' nal dependir
g on the
nature and extent of the repair. i'
1,0Q0 � Oc, c-Q= Cc�S -�- �a� i
q
n �C
� - a
f
I, as owner,agree to the conditions stated on this form
SIGNA R "�" -� TITLE DATE -7
1 -U
(owner)
I, the septic installer, paWaQ t>tt
gnply a Mons of this permit for the septic system re
air
SlGI�ATU.R.� _ "- TITL , • - :�- e ._- .. .LATE
(Installer)
ro oll itio s•
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 du
Aicate showing:
a. Owner's name, Site Street Name, Town and Tax Map number
b. Location of installed components tied to two fixed poirrts
c. System description (e.g.,. 1260 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
it 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
II
Proposal Approved Proposal Denied ❑
"—
ration Date,/
Inspector's Signature & Title Datef Exp'
Repair proposal Is in compliance with applicable codes Yes ❑
No C�
COPIES: PCHD; Owner, Installer
PC-RP 99ML Rev{
2iO7
Q o I James and Kathi Pastena
v n 1 331 ®scawana Lake Road
. = Putnam Malley, IVY
;Town of Putnam Malley
.Pess�
c ptlon of Repak to Systeime
nssiallation of 1,000 Gallon Concrev
z `,Peptic Tank and Y x 50' of Infiltratoi
With 1 %s" Mashed Stone for Fields
Do m - Philip Leonforte (License #1022)
2 ' Precision Excavating Inc.
i 3 Rochambeau Road
:,Garrison, NY 10524
;(845) 736 -0571
Installation Completed: 7 -23 -09
30'
�. A -1 =48.5' B -1 =29.5'
h� {
=A -2 =81' -2 =g1'
.A -33 =17' R -3 =39'
i cy. _
. �+ ._...
VP
Sheet t of
PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEAT1,1•
FIELD C ITY REPORT
ADDRESS: 331 Q, 4� ZAa PUZA-AW 112&46S1
Street Town State Zip
PERSON IN CHARGE
;' A T'N-4- -7 AI -a
Name and Title
TYPE OF FACILITY
FINDINGS: 7-,L-t!Yk.
01
_:t7
Signature and Title
RIFPORT RP.C.FTVE1)-RY:
I acknowledge receipt of this report: SIGNATURE:
02/96 Title:.
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PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
t: tntoFrahl -Use Q
❑ LY1. Repair Permit. issued in last 5 years ❑ of
❑ Repair within Boyd's Comers, W. Branch or Croton Falls Res. Del,
❑ Repair within 200 ft. of a watercourse or DEC - mapped weband tt ❑ . Moir
SITE LOCATION '331 �a6eTOWN P..An,�rn ya l TM #
Watershed
Review
OWNER'S NAME M 2 n a-�±en :4 PHONE # $y —
MAILING ADDRESS ��.. P" rn Qakleu
APPLICANT (�-e-Gi F,cCc� Jc? (� tl t C�� I "
Name & Relationship (i.e., owner, t nant, contractor)
DATE FACILITY TYPE S". 0�4 Z:4r-ntIL4 PCHD COMPL
PROPOSED INSTALLER �4`QC i r�� �-+n 1 Xc tai-L'nG PHONE #
ADDRESS 5 Rnc 6rnloPa�s JRA Giof Sore REGISTRATION /LICENSE #
Proposal (include a separate sketch locating the house, property lines, all adjacent well
feet of repair and the location of existing and proposed system)
NO The Department may require submittal of proposal from licensed prgfession I depend
nature and exterjt of the repair.
1,000 �I o tor-e--'(7
11111201110 M-1 Rom
LINT #
)aa
within 200
Q on the
I, as owner,agree to the conditions stated on this form
SIGNA UR —� TITLE AA A), -\A— DATE -7 1 �
(owner)
I, the septic installer, a t ply a itions of this permit for the septic system re air
- SIGNki UFiE TITLE'° mss: c1e.( "DATE
(installer)
Proposal approv 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 du lic
a. Owners 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
11 )4
s A!?
- 35C9
showing:
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
is in compliance with
COPIES: PCHD; Owner; Installer
PC -RP 99ML
Proposal Denied
codes
FI
20 F
D
Yes ❑
3n Date
No Q' /
Revi 2/07