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BOX 28
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03513
ALLEN BEALS, M.D., J.D.
Commissioner of Health
r. �'' %'�>E`RT' �VIURRIS, P.E., MPH y
Director of Environmental Health
November 19, 2014
DEPARTMENT OF HEALTH
1 Geneva Road, Brewster, New York 10509
Phone # (845) 808 - 1390 Fax # (845) 278 -7921
Karen Harel
215 West 91't Street
Apt. 125
New York, NY 10024
Re: Addition — A- 151 -14
No Increase in Number of Bedrooms
71 Rochdale Road.
(T) Putnam Valley, T.M. 74. -1 -5
Dear Ms. Harel:
MARYELLEN ODELL
County Executive
This Department has received and reviewed the plans for the proposed addition 'to the above
mentioned residence. The proposal for the addition has been approved as per plans bearing the
approval stamp from this Department dated November 19, 2014. The addition is approved with
the following conditions:
1.. The total number of bedrooms must remain at two without prior approval by this
.;...........:.- :....w.:... -... �._._
2. The area of the existing sewage disposal system and its expansion area must be
maintained.
3. All plumbing fixtures must be updated with water saving de_ vices, i.e., new low flush
toilets, restrictors for'shower heads and faucets, etc ...
4. The approval is for the modifications only and does not validate any construction shown
as existing that has not obtained proper approvals from other agencies having '
jurisdiction.
5. This approval is valid for two (2) years and expires on November 19, 2016.
Any permits or variances required under the jurisdiction of the Town of Putnam Valley are the
responsibility of the applicant.
If you have any questions, please contact me at (845) 808 -1390 ext. 43261.
Respectfully,
Gene D. Reed
Principal Engineering Aide
GDR:cml
cc: BI (T) Putnam Valley
1:.
is
R. / P=kl tag,-/
ALLEN DEALS, M.D., J. D. MARYELLEN ODELL $00
Commissioner of Health - Cownly Executive
v9^'. ��i1 "<'A`�1C:sF�- .CAf+[+la..+^Pfa:. ••Y a�f... b` ,.b T. �rvq� -•+Y 4lv: - ^ -v v4! ^i�.Ma'A•- L'�f•l, rLITCTBV�'e'iPwC Cr. tr.- h`r -. y.� .�:o�iT.'�:.. :�!r. �+ =ry -�•
ROBERT (MORRIS, P.E. NTH
Director ofEnvironmental Health
1 Geneva Road, Brewster, New Fork 10509
Phone .# (845) 808 -1390
AIDDITION APPLICATION - RESIDENTIAL ONLY
Atro..;>fi Cad ��,s7'ItIS �oe-, -
r
Owner's Name: 1� � l %�L- Owner's Phone #: ��' °1� 4�>
Site Address: ! � �� D�� 'own: RV � Tai leap #
Owner's Mailing Address: �1 `�1 S% 57' ( ZS Illy A1�!
Owner's Signature:
(Description of Proposed Addition: 1ei d1 tit. j`
Hmf,R
*Number of existing bedrooms: Total number of bedrooms (existing + proposed):_
*. ((FRONT CERT. OF OCCUPANCY OR CERTIFICATION FROM MOLDING INSPECTOR)
* *Any addition which is considered a bedroom requires formal approval of plans (Construction permit)
epar€d -b.a ProfessianalEdIncr'or Registered - Architect m accordance -with a pp licable.�sectis ofthe - -
Putnam County Sanitary Code.-
Please submit this form and the following to Putnam County Department of Health, 1 Geneva Rd,
Brewster, NY 10509, Phone: (845) 808 -1390.
1. Certified check or money order for $100.00.
2. Two sets of sketches of existing floor plan (drawn to scale, all Paving area including basement,
to be shown and dimensioned and use of each room specified). (See Section 3.c of Bulletin HA -1)
3. Two sets of proposed floor plans (drawn to scale — with name, street and tax map #)
* Non - professional sketches are acceptable and preferred. (See Section 3.d of Bulletin HA -1)
4. Copy of survey showing all well and septic locations on the subject property to the best of your
knowledge. Contact this office with any questions.
5. Copy of Certificate of Occupancy from the Town or Certification from the Building Department
with legal bedroom count of dwelling.
OFFICE USE
COMMENTS
Rev. July 2013
5.
w ALLEN BEALS, M.D., J.D.
Commissioner of Health
'l• / L �y`O'.'Y AJ'1 i�!,M Vi'Y��.�;..11"•LJ.'
Director of Environmental Health
a
MARYELLEN ODELL
County Executive
DEPARTMENT OF HEALTH
1 Geneva Road, Brewster, New York 10509
Phone # (845) 808 -1390
Fax # (845) 278 -7921
Town Legal Bedroom Count& Proposed Addition Status
Re: Xf€ , (Owner's Name)
Tax Map #
Address:
Town: 2�nri Vd�
Year Built: 'g150
According to records maintained by the Town, the above noted dwelling,
is W In compliance with Town Code.
Is not in compliance with Town Code.
The Legal Bedroom Count is:
This information has been obtained from:
Certificate of Occupancy:
Other:
The plans for the proposed addition are considered:
/ Addition to existing house only
e/
Teardown and/or re -build allowed under Tow" n Regulations
04dl,ra 14
OLA
Building Inspector Date
5.
ALLEN BEALS, M.D., J.D.
Commissioner of Health
ROBERT MORRIS, P.E., MPH
Director of Environmental Health .
November 3, 2014
Karen Harel
215 West 91" Street
New York, NY 10024
Dear Ms. Harel:
DEPARTMENT OF HEALTH
1 Geneva Road, Brewster, New York 10509
Phone # (845) 808 =1390 Fax # (845) 278 -7921
MARVEL .,EN O D1ElLL
County Executive
Re: Addition- A- 151 -14
71 Rochdale Road
(T) Putnam Valley, T.M. 74.4-5
I have received and reviewed the plans for the proposed addition to the above mentioned residence.
Based on the information submitted, the above mentioned addition cannot be approved for the
following reasons.
1. The proposed loft is considered a potential bedroom.
2. The legal bedroom count for the dwelling is two -. The potential bedroom count of your
proposed addition is three.
3. The addition of a potential bedroom requires this Department's approval of a revised. septic
....system - l frsr a r ,f�ssio. dagi r` do .. ��r__ ._��.:.. r.......
Please revise the proposed floor plan to reflect no more than two potential bedrooms, or have a
professional engineer or registered architect design a sub-surface. sewage treatment system meeting
present code requirements.
If you have any questions, please contact me at (845) 808 -1390, ext. 43261.
Sincerely,
Nzloeek
Gene D. Reed
Principal Environmental Engineering Aide
GDR:cml
P.O. BOX 232
FISHIQLL, NEW YORK 12524
(��TC T �T ('t D n D j(��T (845) 897.9400 PHONE
0111 SMWTd.Q��1;XO$� Ol�t'1Tl�JI�"'-` r (845) 897.9490 FAX , •
www:l`Ty[rzioNSi�ivcTiar
Kay Harel
71 Rochdale Rd ev k a 10 ACo , ^ L 2 iGv�
Putnam Valley NY 10579
October 1, 2014
RE: LETTER OF AUTHORIZATION
To whom it may concern;
This letter is to serve as my authorization allowing Nurzia Construction Corporation to submit an
a
application for a Demolition permit, Building Permit or an addition permit (BONA) on my behalf.
If you have any questions or need further information, please do not hesitate to contact either myself or a
Pete Nurzia of Nurzia Construction Corporation (845) 897 -9400. j
Sincerely,
Kay Harel
CUSTOM HOMES - LAND DEVELOPMENT - CONSTRUCTION AND REAL ESTATE MANAGEMENT
COMMERCIAL CONSTRUCTION - REMODELING - INSURANCE RESTORATION
m
Three
.: .. ». _'rs�;':��y�y,;'.�d. -. �wp d.tF..�b -Fbw-s r �2.. .r, .% si;,`. � .. .. F- •t�.:�++ +�:�-y�`si�i '
If you have.any questions or. concerns, please contact t#�. Three Avows Planning & Building Committee
Chair. as %llovsis:
.- �..ry�... •�ws�w +l. ay.• ..: .�.. � i c s. �. .....,.. ..�...r. wu e. � •.yr +. —�
Ty
PUTNAM COW
OFFICE OF EA1ERGEMQY MMAGEMENT
Thomas C: Lannon, sr.,Director
Emergency Management /.IT
April 15, 2013
Kay Harel
71 Rochdale Rd
Putnam Vall6yj NY 10579
Dear Resident
-MaryEllen Odell
County ExecuVW6
In a recent review of 911 addressing for your community, it became.. apparent that there
was an issue with the current addressing. Numerous. houses are on side streets off. of Ro.chdale
Rd, yet still use a Rochdale Rd., address. ' From a mail delivery point of View this was not an
issue, however, from an emergency re'spo:nse point of view, this is not in conformanc6 vififth the
county policies..
Basied on that information, we are re-numbering the units within this community utilizing
now. house numbers.' While we reafirielhat it is. not easy to have-a new
ad -it is importantfor your safety: Rif yourin -addrds—h 'thoattachbd
dress, ew s, please see
Please be sure to post. your address.number.,6t the entrance to your driveway and on
your building. Posting y.o6r house number can'greatly assist the police,,fire and ambulance
services in locating you In the event of an emergency: We Will. notify the Putnam Valley Post
Office of these address chdnges�. We Will also notify Verizoni for the residents that we have
landline phones for.
I Would like to'thank Esther Brill for her assistance. If you have any quettlions with your
aiddress,.please'feel free to contact Carol at (845) .808-4005.
v ry truly yours,.
Carbl Cavaflaro-
Putnam 911 Coordinator
• -
_ _ : <aii isx;l.' S\ �il.. r'' �`zS'.K','�",C'i:4fi�w���.l,..' .�'�,°,a�.
'Ebert Ln
Wisotsky, Eric & Megan
20
vvy rv, 3,.
x
- t
Ruben, Julie
�z w. x•.
8
Abrams, Brad/IUarup, Irene
28.
11
Brown, Helen
.26
12
Piano Mountain Rd
-, _ s - �BiKO. i�f.. • - -.: 4: •.- �.YiY��iij:r:»`i>: x.. i'_:r _'ZCa�?�:ii9c+ t
.. ..v.. w �'1 ye"::i!tr`�:.
�.% =:_w
,t •f" �^~ �V.��w!'Y �, OP Y�:C.). �'. •'S'•A
Tulip Tree Ln
Dmoker, Nina & Hal 51 10 .
Zolot, Bruce & Joan 53 16
Broksky, I(Oren. & Gabe 55 20
Gallagher,,- OkelMarsten, Ro)ie . 57 30
Hall-, afcy & Ron -/ Levine, Roberta . 59 27 •
Cordes;: ldgar/Humphrey, Sylvia 61 23
ii�ig��rrl�[ike
Rochdale Rd
'Ebert Ln
Wisotsky, Eric & Megan
20
2
Ruben, Julie
2-2
8
Abrams, Brad/IUarup, Irene
28.
11
Brown, Helen
.26
12
Piano Mountain Rd
Schaffer Ln
White, Eleanor Eleanor & Hilary
30 •
9
White, Bruce &Lisa
32
11
Pita, Dorothy
34
15
Bogin, Merle/Berger, Wally
36'
17
Sklar, Rick
38
1'9
Tulip Tree Ln
Dmoker, Nina & Hal 51 10 .
Zolot, Bruce & Joan 53 16
Broksky, I(Oren. & Gabe 55 20
Gallagher,,- OkelMarsten, Ro)ie . 57 30
Hall-, afcy & Ron -/ Levine, Roberta . 59 27 •
Cordes;: ldgar/Humphrey, Sylvia 61 23
ii�ig��rrl�[ike
Acorn I_n
ier /StdOh& is, Mitchell ° 73 ` t `
_ 7
.16
►1 Freund, Vivian
75
26
ie! Ctidstina : -..
7T , _ r .. ....
y . _27
n/Shaffer
79
17
Piano Mountain Rd
Warsten; RoAe
109-
9
107-
10
/Aislirig
105
2
- ..
Primrose Path
argss, David
118
4 •
iV silaIds, Stelio
120
8
arr
122
12
124'
14
�J• q,. �sR+: e'- Fsr- ...x:. }���..r•.2LL•:'��.;.'r.�z .. -l:�in :.r= aa.:.... ri�r�••.� ✓.r :•.�' -.ar: r.,.: •: p' -� :v ,o.- ..:.;...lwca v
S—add MARC L. SAIDEL
SHERYL M. SAIDEL'
(� ERIC M. SAIDEL
ATTORNEYS AT LAW 'Also admitted In Connecticut
PO. BOX 308 PARKSIDE CORNER ROUTE 202 YORKTOWN HEIGHTS, NY 10598 ERIC H. HOLTZMAN
TEL. (914) 736 -6500 FAX(914)736-6581 www.saldelesgs.COM of counsel
VJA UPS
Karen L. Harel
215 West 91st Street Apt. 125
New York, NY 10024
RE: Site #40
Three Arrows
August 9, 2013
Dear Kay,
Enclosed please find the following:
1. Acceptance of Assignment and Assumption of Proprietary Lease
2. Stock Power
'J I. -Ass riine]it Rrop:aet j+:Leasa:
.p..r.ya -�.• �y
4, New Stock Certificate
Please keep these documents in a safe place. you have any questions. please call or e -mail.
Very truly yours,
SAIDBL AND-SAIDEL. P,
/ SHERYL M. SAIDEL
SMS:pe
^. C. .SIGNME.•A�Ni.�•':,�.4a a; hi R_r.a�•��s M:r"�a- =' „.�. w. %rirv� .��7 -L:u a...� .�.:e..i,�i� -. ','�,.o..i
ACCEPTANCE OF AAT AND. ASSUMPTION OF
PROPRIETARY LEASE
KNOW THAT KAREN L. HAREL, the undersigned Assignee named in a certain in-
strument of assignment dated . 6 1 -+1 2013, executed by KAREN L.
HAREL and YAIR H. HAREL, as JTWROS, Assignor therein, in order to induce
THREE ARROWS COOPERATIVE SOCIETY; INC.,. Lessor therein and owner of the
property at Barger Street, Putnam Valley, New York to consent to the aforementioned
assignment of interest in the proprietary lease and to transfer the shares of the Lessor
to which said proprietary lease is appurtenant, and in consideration of such assignment
and the consent of the Lessor thereto, the undersigned HEREBY ASSUMES AND
AGREES TO PERFORM AND COMPLY with all the terms, covenants and conditions of
the proprietary lease to be performed or complied with by Lessee, as If the undersigned.
had originally executed the proprietary lease as Lessee, and further agrees that of the
request of the Lessor, the undersigned will surrender the assigned proprietary lease to
the Lessor and enter into a new proprietary lease for the remainder of the term thereof,
in the same form and on the same terms, covenants and conditions as the assigned
proprietary lease.
IN WITNESS WHEREOF, the Assignees have duly executed this acceptance
and assumption instrument on • uf-te Lw,>�' 7 , 2013
L. HAREL
State of New York }
County of �,`jr -0e% } ss.:
On 8 1-4 1 f 3 before me, the undersigned, personally appeared 6A r..er1 L... I-t,�,;,J
personally known to me or proved to me on the basis of satisfactory evi-
dence to be the individual(s) whose name(s) is (are) subscribed to the within instrument and
acknowledged to me that he /she /they executed the same in his/her /their capacity(ies), and that by
his /her /their signature(s) on the instrument, the individual(s), or the person upon behalf of which
the individuals) acted, executed the instrument.
(signature and office of individual taking acknowledgment)
MELISSA LEE RIVERA
Notary Public - State of New Yark
NO. 01 RI6263073
Qualified In Bronx Cou ty��
My Comm;ssion Expires
P �
..:..�•� ?.• ..,�, ,�•.�._ .. :;� r . ,�:.- < � ...:...,� �:�� -, ..�.;:� x: �� ,t,���'Iiree4Ai•i °ows'
Putnam V lley, NY
SUMMARY OF PROPERTY
Address: 71 Rochdale
Putnam Valley, NY
Description: Size /sqft
1,154
Rooms
5
tr ,
Bathrooms
1.5
Loft sgft
0
Loft Utility
n/a
Basement sgft
0
Basement Finish
Unfinished
Basement Utility
Average
Heat
Electric
AC
Central
Insulation
Partial
Water
Well
..; ...... -. _ _ .: ....n..... _..�............
�C .+rs .. «. .. .. ... - .... .a .
.n..r.. � �F- -�•rt. ca..« .. .. ... .. r
Deck sgft
� .. ...a a ..
358
Patio Size
None
Covered Porch sgft
0
Fireplace /Stove
Fireplace
Shed
Small
Miscellaneous
None
House Appeal
Average
House Condition
Average
Site Appeal
Above Avg
Site View
Average
Indicated Value: $140,118
75
? 2 OG.) y
Q:
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in I
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W, M. RATIVE
,MW�
=mm--T4w-4-224
no
I A.
t7-2�7
KAREN L. HA#tEL
MIA TY INC.
1 m
October 1, 2014
Putnam County Department of Health
1 Geneva Road
Brewster, NY 10509
ATT: Gene Reed
RE: Application for addition
Dear Gene,
P.O. Box 232
RSHmLL, NEw YORK 12524
(845) 897 -9400 PHONE
www.NuRziACoNsTRucnoN.coM
VIA HAND DELIVERY
Please find attached application for addition. We are proposing a complete knock down / new
build. The future house will be the same footprint, location and current bedroom count as
existing. Please review and give me a call with any questions. I can be reached at 845. 897.9400 or
(914) 490 -6492.
Our company is acting as agent on behalf of the owner. We have attached a letter of authorization
F'rf/'P1°!`��F,62fFYP'r_ .. ,»... «_ ..,.....--- •rv_.a....._.a,..... --.- �—....-.:_..... ..-.. �.....::..._..- .- �— ..�— ......�......._._..... ,- ....r......... - ....�:v- :....._:::�..,:.'_.
Sincerely,
President, Nurzia Construction Corporation
CUSTOM HOMES - LAND DEVELOPMENT - CONSTRUCTION AND REAL ESTATE MANAGEMENT
COMMERCIAL CONSTRUCTION - REMODELING - INSURANCE RESTORATION
Date /19�J'° .... TOWN ` TNAM VALLEY Application No.
APPLICATION FOR BIIII.DINC PERMIT. Zone District
` i
Application is hereby made to erect (alter) :. ��w°.,....Work to start x _/ •., v.
................ .
......
Location•of Premises — Street or Road ..... ...... ..... ............... .
SEC............ BLOCK ........... LOT ........... FRONTAGE Depth. % vRear.... . .
ACRES (other description) or number of square feet .......... .................
/�,. /r, .
ADDRESS .:` .. q m ' ''2`e . _1
Dimension of Building
Width D,eith Stories
X. X X
X x
Type foundation,
Room with window area ..... .
Sewerage type
Size of septic tank .. ,..:
Lineal Ft. Drainage ..............
Size of dry wells .................
Additional information: ..........
. T'. . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . .. .
this appl�icqtion must be accompanied by copy of surveyors map and complete plans, specification, and all information
equired y. oning Or i a an Sanitary Code when requested by inspector.
I, ........ the applicant do hereby a that th b Wst ements are
rue to my knowledge and elief. Fee ° ' Signature of Applicant .... .... ....
1a,. .
EX
USE
(
CO STRUCTION I
ROOFING
I
LAND
FAMILY
IGOD
WOOD SHINGLE
PAVED
2 FAMILY
STEEL
-
"ASB. SHINGLE
—
XIRT
LOG CAB EX
BRICK
I
TILE
OILED
UNGALOW
CONCRETE
METAL
i
SWAMP
APARTMENT
STONE
BROOK
STORE
(�
FNDTNS. I
INTERIOR I
LAIC F.
STORE & APT.
STONE
ROOMS
DAMS
STORE & OFFICE
ONCRETE
I
APT. ROOMS I
SW. POOLS
OFFICID
AO
f3LOCKS
APT.
TEN. COURTS
GAS STATION
BRICK
i
ATTIC'OPEN
GARAGE
PIERS
i
iI
FINISHED I
OTHER BLDGS.
`EXT.
WALLS
PORCHES
BARNS
BASEXENT
V
WOOD
y X FRONT
SHACKS
PART
BRICK
II
X SIDE 1
COTTAGES
FULL
BRICK VAN.
X REAR
BUNGALOWS
CEMENT FLOOR
LOG
{�
A ENCL. I
ELECTRIC
FINISHED
SHINGLE
PHONE
GARAGE B. IN.
COMP.
FURNACE
FIELD: STONE
Width D,eith Stories
X. X X
X x
Type foundation,
Room with window area ..... .
Sewerage type
Size of septic tank .. ,..:
Lineal Ft. Drainage ..............
Size of dry wells .................
Additional information: ..........
. T'. . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . .. .
this appl�icqtion must be accompanied by copy of surveyors map and complete plans, specification, and all information
equired y. oning Or i a an Sanitary Code when requested by inspector.
I, ........ the applicant do hereby a that th b Wst ements are
rue to my knowledge and elief. Fee ° ' Signature of Applicant .... .... ....
1a,. .
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Date: kill i't�-
Putnam County (Department of Health
Division of Enviroamental Health Services
SSTS Repair —Final Site Inspection
2W ' Inspected•by: Lj.-/
1. Type of System: Conventional ❑ Alternate ❑ Comments:
2. Se tic Tank Y
a. Septic tank size -1,000 ... 1,250 other
b. Septic tank installed level ......................
c. 10' minimum from foundation ..................
d. )[Distribution Box
i. All outlets at same elevation (water tested) ...
ii. Protected below frost .......... ....................
iii. Minimum 2 ft. Original soil between box &
trenches
e. Junction Box — ro erl set .....................
f. Trenches
i. S stemcompletely opened for inspection
ii. Length required Length, installed
'AP!F
Installer: E�•S •
N/A I . Comments
iii. Pipe slope checked ... ...............................
iv. Installed according to plan .....................
v. 10 ft. from property line —20 ft — foundations ...
vi. Size of gravel % - 1 '/2 " diameter clean .........
vii. Depth of gravel in trench 12' min
' unum
...._ ..:.: , r .� ._.:..... _.... -
wY......_... �sr..^.. rta.". s..... v;. wSi< W�. '[F^*w..�....W- .......p.-rvym�V VS.m.r -aa.., ro..e+W .-.sv a.aw...aM w.. +.gyp
�Le+.._. Pi
.:,..
°.a..�..a.I^...._..y��'Y..wn.O Yrrir.•
ea ^i
viii. Ends capped .... ...............................
. Pumg or Dosed S stems
3. Sewa •e System Area
a. SSTS Area located as per a roved plans .
b. Fill section —
c. Distance from water course /wetlands
4. Overall W6rkmanshi
a. Boxes properly grouted and installed correctly ...........
b. All pipes flush with inside of box .........................
c. Backfill material contains stones <4" diameter .........
d. Curtain drain & standpipes installed according to plan
e. Curtain drain outfall protected & dir to exist watercourse
f. Footing drains discharge away from SSTS area .........
g. Erosion control provided ............
.Additional Comments: 'Q vi r
C4 lbsA5(
RFS1 Rev - 011312
C0
PUTNAM COUNTY HEALTH DEPARTMENT
.DIVISION OF ENVIRONMENTAL HEALTH SERVICES
YES NCY Internal Use Only PERMIT #
❑U Repair Permit issued in last 5 years ` Not in Watershed
;e-Ilepair epair within Boyd's Comers, W. Branch or Croton Falls Res. ❑ Delegated
1:1 within 200 ft. of a watercourse or DEC- mapped wetland ❑ Joint Review
SITE LOCATION TOWN
OWNER'S NAME S I I �a
MAILING ADDRESS / I/ %L ) i
APPLICANT `:2 t __r J a --1
N & Relatlonshlp (i.e., owner, tenant, contractor)
DATE FACILITY TYPE PS. PCHD COMPLAINT #
PROPOSED INSTALLER PHONE #
ADDRESS �lOr� ��(,yf/l REGISTRATION /LICENSE #
1�
Proposal (Include a separate sketch locating the ous , >roperty lines, all adjacent wells within 2001 -�
feet of repair and the location of existing and proposed systern) r
NOTE: The Department may require submittal of proposal from licensed professional depending on the
nature and extent of the repair.' /"� I —
I, as owner,agree to the con itions stated on this form
SIGNATURE Z T TLE DATE ah )ZT
(owner)
I, the, septic installer, agree o comply with the conditions of this permit for the septic system repair _
NATURE - V» TITLE DATE T
(Installer)
Propgoal gonroved with the following condi 'ons:
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 backfillejlnntil authorization to do so has been obtained from the Department
Yor INTERNAL USE ONLY
Proposal o Proposal ;De;nied
�,Al
InsDectWs Sionature-ArTW DaI6 Ex rat n Date
in compliance with
COPIES: PCHD; Owner; Installer
PC -RP 99ML Rev. 2/07
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