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HomeMy WebLinkAbout3330DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 73.05 -2 -7 BOX 27 r 03330 PUTNAM COUNTY HEALTH DEPARTMENT DIVISION OF ENVIRONMENTAL HEALTH SERVICES P, OPOSAL FOR. REWAGE TREATMENT SYSTEM REPA!l� YES N- Internal Use Only PERMIT # ❑ Repair Permit issued in last 5 years ❑ of in Watershed. ❑ Repair within Boyd's Comers, W. Branch.or Croton -Falls Res. Delegated . ❑ Repair within 200 ft.. of a watercourse or DEC- mapped wetland El Joint Review. SITE LOCATION id q c-- AVM TOWN Pit&lallt Va TM #_ " OWNER'S NAME JQ, IC-9 aNe .it4e * /PHONE # 9-. S-- ZX'11 -Z7�? MAILING ADDRESS 4,1t Ak u h N'( to S- -79 0 APPLICANT '�J-CLC� Ueb/1e J -0. Name & Relationship (i.e., owner, tenant, contractor) DATE J �^ a FACILITY TYPE S� �(C PCHD COMPLAINT # V PROPOSED INSTALLER / I L k Z � ( o �t S - � PHONE # /S1� 2 � ` ski �P ADDRESS 13 u C/� Lc 06 /a V RP� REGISTRATION /LICENSE # �' e 3 % tj cfoVA 1�_ (I 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 \� I, as owner,agree to the conditions stated on this form SIGNATURE , p� TITLE DATE IG /ZZ J00 (owner) I tp u14 i _ la ' ryu r irzinhr n ith tho �nn.�� ��� .�f ±f �fc. n�.mi +�+r ti,n ten.. +, -� = . i:.: . f'SL' h .. , .r t o.p.,. syo. ri-r -,put. � r/ SIGNATURE r TITLE t DATE (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 backfille until authorization to do so has been obtained from the Department. INTERNAL USE ONLY Proposal Approved r`s Signature & Ti al is in compliance with COPIES: PCHD; Owner; Installer PC -RP 99ML Proposal Denied cable codes F' Z-,0-/Z 7 _Dae Yes !! ✓ 2 Z02 ' Expir tion _ate E) No 31 / Rev" 2/07 7. 196 y GARAGE,. �f Lo t °i JL RI�)GF- AV F- 4 •,1 3 1� 0 PUTNAM COUNTY HEALTH DEPARTMENT DIVISION OF ENVIRONMENTAL HEALTH SERVICES a P OPOSAL FOR SEWAGE TREATMENT SYSTEM REPAID O YES N internal Use Only PERMIT # ❑ `Repair 0. Permit issued in last 5 years ❑ of in Watershed ❑ Repair within Boyd's Corners, W. Branch or Croton Falls Res. Delegated El Repair within 200 ft. of a watercourse or DEC mapped wetland El Joint Review — ^ SITE LOCATION IZtd 0 C-_ AVC TOWNP "kUAI, Ua e& TM # OWNER'S NAME C e.1(4e TO (PHONE # 9't1$ ZR`GI -27, MAILING ADDRESS ✓t ilk Q At (--!z N N 10E %Q APPLICANT TOLC5 Ue 1\ C--c Name &�Rel /ationship (i.e., owner, tenant, contractor) DATE J �^ C O FACILITY TYPE (C�- PCHD COMPLAINT # PROPOSED INSTALLER 1"~� Z e a S PHONE # ADDRESS �� C� ! Gi CIS k 06 0 � �' REGISTRATION /LICENSE # (� C 3 Proposal (include.,separate sketch locating the house, property lines, all adjacent wells within 200 feet of repair Effid1he location of existing and proposed system) r� NOTE: The Department may require submittal of proposal from licensed professional depending on the �\ I, as owner,agree to the conditions stated on this form SIGNATURE. TITLE DATE 16 - (owner) I,.the septic inst le, 4 ree to comply with the conditions of this permit for the scptic systdmr SIGNATURE ' TITLE DATE (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 i completed SSTS repair will function. 5. No completed work is to be backfille until authorization to do so has been obtained from the Department. 7 INTERNAL USE ONLY Proposal Approved L9' Proposal Denied ❑ I pector's Signature &Title sal is in compliance with applicable codes Yes COPIES: PCHD;.Owner; Installer PC -RP 99ML „A ffizK iFa_ _ �Z O Expir tion —ate/ ❑ No Rev. 2/07 Sheet of PUTNAM COUNTY DEPARTMENT OF HEALTH „.1vL1nN!F,vTA1.11 F.��'?_.�rII FIELD ACTIVITY REPORT ADDRESS: Street Town State Zip PERSON IN CHARGE % %, 71nR TNTFRVTFWFT): ,"/4 C eyzUS , � /2� Name and Title TYPE OF FACILITY :rid Signature and Title REPORT RFC'FTVFTI RV. I acknowledge receipt of this report: SIGNATURE; 02/96 Title: men tie -e UTNAM COUNTY HEA,�TH EPA�?TMF "eT - tN�iHONI�IEN AL HEALTH SERVICES THIS IS NOT A REPAIR PERMIT PROPOSAL FOR EXPLORATION OF SEPTIC SYSTEM FAILURE All information below must be fully completed prior to any scheduling 4z;& SITE LOCATION P-diy1 ant Ua1le v TOWN TM # OWNER'S.NAME Jl1' .e ©nom PHONE# 9/�/- yg2- -0766 MAILING ADDRESS q a ; PROPOSED CONTRACTOR /INSTALLER �� 4,,�dA5T/`ye- roA PHONE # . 2 y6 ADDRESS /O M REGISTRATION /LICENSE # Reason for exploration: ❑ failure to surface ❑ back -up in house ❑ find limits of system for repair ❑ other (explain below) FOR COUNTY USE ONLY Inspector's Signature & Title ent Date: p 2 ? Time kly:excel:septic Date /O!3p m n`•/ ,ece alle et�tic;, tat dear N:79' 48'06" YL Ir •o-: j tl� �K wire ' !a 1201 3706 -- �tnnt.�f •fr -lam ;sct RnFtcD. To: ULSTER E8MS BANK. ;w} n' blf- I vjRJ RV EYED:- APRIL r t99t �!i4lROUGHT TD DATE 1 b ;c e ;r• �t BY. JOHN .C. MOfFMItNN '✓ i�l 'Ip irowe �- j . .!k 122 �E c m n`•/ ,ece alle et�tic;, tat dear N:79' 48'06" YL (L1 �1 J !f } wail /�,j off. r, 4,v i CP y- 9: u- teKe .ICtko4 ksce^ ' � feMe ACREAGE = 0.4958± ACRES 21,598± Sq. FL I 9 i Gr(iilc►tie,e bv.w a.e r.td (e1 Be.11, rifle Co. L C-mtt, (e, Hsi. h....cAe., .a{y CftrQGcefiels .n net h.e.krebk I. r6ugwv%l 1a.L risk Co, of D.Rrn AN cerfiricAf6m Lrre" Mf •a1d fe Ittil map eed cep:a Owed e.iy it "W _p v ,w copse, beir fl,.. imprsad l d Ike tu!• ,ft -tbM VOe.IYr. apvwe Wftbft 'N it hereby ce4irwo 161 Ks " ey eai prep.r.d i" ."dams ,;tb 44. euic(il,q Cede of pr.c4:ce br Land SYe. adoptrd 6y 4. Nw Y-k W4 AnetiNiN .1 he r o f f Rte, wk 1 Sam I �reloleilp yl �� f axl age ' S �I► � s; *cc •; � Iraece I e i ''L- ewtl.n d...e.rey� rril � y 7 Story Roma Raieanoe 1 rcWdwce refeblirg'��'.Sj � �- fY • S st.rp trove .eeJ. .:; JOHN S. ROMEO 'PC. . o C:emaiiRf 'F.,rR..lreot;! laid $rr.ty0iy i t lVORTHRIDGE ROAD �i PEElCSKILI.. N. Y. t L. S. j i i �K wire ' 1201 ;sct RnFtcD. To: ULSTER E8MS BANK. ( vjRJ RV EYED:- APRIL r t99t �!i4lROUGHT TD DATE 1 b (L1 �1 J !f } wail /�,j off. r, 4,v i CP y- 9: u- teKe .ICtko4 ksce^ ' � feMe ACREAGE = 0.4958± ACRES 21,598± Sq. FL I 9 i Gr(iilc►tie,e bv.w a.e r.td (e1 Be.11, rifle Co. L C-mtt, (e, Hsi. h....cAe., .a{y CftrQGcefiels .n net h.e.krebk I. r6ugwv%l 1a.L risk Co, of D.Rrn AN cerfiricAf6m Lrre" Mf •a1d fe Ittil map eed cep:a Owed e.iy it "W _p v ,w copse, beir fl,.. imprsad l d Ike tu!• ,ft -tbM VOe.IYr. apvwe Wftbft 'N it hereby ce4irwo 161 Ks " ey eai prep.r.d i" ."dams ,;tb 44. euic(il,q Cede of pr.c4:ce br Land SYe. adoptrd 6y 4. Nw Y-k W4 AnetiNiN .1 he r o f f Rte, wk 1 Sam I �reloleilp yl �� f axl age ' S �I► � s; *cc •; � Iraece I e i ''L- ewtl.n d...e.rey� rril � y 7 Story Roma Raieanoe 1 rcWdwce refeblirg'��'.Sj � �- fY • S st.rp trove .eeJ. .:; JOHN S. ROMEO 'PC. . o C:emaiiRf 'F.,rR..lreot;! laid $rr.ty0iy i t lVORTHRIDGE ROAD �i PEElCSKILI.. N. Y. t L. S. Uj t.l l-;.O�GMMEIi1T(i ■[tOw GRA Di li aM.Y MOT 6NOYN1.1 0 1. Ftenims silwn hereon belts¢ as Ids fig & i30 os shown etlt/t1Ed "IIA:00 of Camp loOkOu crop teOS (3edlnfhe tlffiit:rs OI Cgl/ify t.'}pt2 Of R7fflOR/Courtly Mop 79C , soie'rots tlf6G SAoiR+ entitledeAln�tlded Mop of Lnokmrt'sow.,op wos tied in ' dfrc.es of Ganity Clerk of :.otnty as mop tZ1IL_ 2 Tavel of Pttttwm va" lac a6ignatiari sedim154 �ocR Lot 26 3, Wso tinotwl an'' 4 Ribgt SURVEY OF PROPERTY FOR RUSSELL. a 8, bNiBERLY N. NGAC,ARROW SITUATE IN THE 'f0'+KN OF PUTNAM VALLEY PU7NAM COUNTY NEW YORK SCALE: 1 6UwyCYIA A6 IM ►DLECi(iIOM NYS L N0.48955 BY. JOHN .C. MOfFMItNN 0 1. Ftenims silwn hereon belts¢ as Ids fig & i30 os shown etlt/t1Ed "IIA:00 of Camp loOkOu crop teOS (3edlnfhe tlffiit:rs OI Cgl/ify t.'}pt2 Of R7fflOR/Courtly Mop 79C , soie'rots tlf6G SAoiR+ entitledeAln�tlded Mop of Lnokmrt'sow.,op wos tied in ' dfrc.es of Ganity Clerk of :.otnty as mop tZ1IL_ 2 Tavel of Pttttwm va" lac a6ignatiari sedim154 �ocR Lot 26 3, Wso tinotwl an'' 4 Ribgt SURVEY OF PROPERTY FOR RUSSELL. a 8, bNiBERLY N. NGAC,ARROW SITUATE IN THE 'f0'+KN OF PUTNAM VALLEY PU7NAM COUNTY NEW YORK SCALE: 1 6UwyCYIA A6 IM ►DLECi(iIOM