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74.17 -1 -22
BOX 29
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PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
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SITE LOCATION
OWNER'S NAME
MAILING ADDRESS
APPLICANT
Internal Use
Repair Permit issued in last 5 years
Repair within Boyd's Comers, W. Branch or Croton Falls Res.
Repair within 200 % of a watercourse or DEC - mapped wetland
Lff' Not in Watershed
❑ Delegated
❑ joint Review
//Review
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NE # gK-6W C'D
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Name & Relationship (i.e., owner, tenant, contractor) __
DATE -Z6 --f FACILITY TYPE tX N):ICHD COMPLAINT #
PROPOSED INSTALLER ng ONE #
ADDRESS � r n6`�h� �` AOL?,, REGISTRATION /LICENSE # ! G 560
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 ted..ota_th' form
SIGNATURE ITLE Cn�a� DATE
(owner).,-"_... .
I, the seti installer, agree to comply with the cond' "ioris of this permit for the "septic system repair ", /"
SIGNATURE TIT E Wi DATE 1 �
(installer)
Proposal aaaroved with the following conditions: 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 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 back Illed until authorization to do so has been obtained from the Department.
INTERNAL USE ONLY
P al pproved M Pr posal Denied ❑
Insp ctor's Signature & Title Date _ / Expiration Date
Repair proposal is in compliance with applicable codes Yes L No ❑
COPIES: PCHD; Owner; Installer
PC -RP 99ML Rev. 2/07
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Jun 20 11 10:42p Leonardi & Son Const.
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Jun 20 11 10:41p Leonardi & Son Const
1- 914 - 736 -9311 p,3
Iro .assal Page two. .,.
LEONARDI & SON CONSTRUCTION. INC.
OWNER: LOUIS LEONARDI
6 CAROLYN DRIVE • CORTtANDT MANOR, NY 10567 .
DAY TIME CELL. (914) 980.3554 OFFICE (914) 736.9010
LIC. #WC- 3112 -N90 ® WC- SEPTIC LLI-7 C #00067 o LIC. VC-560 (CERTIFIED)
rir.r,one A Ci 1..A lima-, 7n _ --T ?HONE .._:1 DATE
We hereby submit specifications and ostimatee for:
.... .... .. ................ ..__......._...__..._._._..... ........ . .... .. ........ __ ..............
_.
_......... _............ ... ..... .__.._..... _.._....._.. .._._......._ ..................
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--------- - - i . . ......
�....._..... __._.........__ ................_._.........__......._._.._._.................
_............- ....- ............
......
lnvulving extra costs will be executed only upon writton orders, and will become an extra
..........._..._........_._................
......
... ...... ...... . ..... .......... ................. ..
or delays beyond our control. Owner to carry fire, tornado and other necessary insurance.
.... .......... ..... _ ........ ... ....
...........__........_.._.. _ . _ ... _.... _..
_. PLEASE. NO' t�........_..` SYSIEMLONG1rVfT' Yl5' NOTC- CfARANY£ ED�DN[ESS�DESIGNfD' "G`fti'L1�NS PAOitf[JN.13V�INE$i -.. _. .
'TANK TO BE PUMPED BY OTHEW AND PAID SFPARAMY .
'NOI.AN DSCAPMGHEMRATION IOTHSM4ANGNADINGDG'TURBED AWAS, IS INCLUDED UNLESS SPECIFICALLY STATED
We propV59 hereby to furnish material and labor — complete in accordance with above specifications, for the sum of:
dollars (S _ ).
Payment to be made as folows:
A FINANCE CHARGE OF 11YZ% PER MONTH WILL BE ADDEO TO ALL UNPAID BALANCES.
CUSTOMER IS RESPONSIBLE FOR ANY ANDALL GOLLE(MON FEES
All rnatorlai Is guaranteed io as specified. All work to completed o a rwrkmanliko
Authorized
rd pr
manner according t0 standard practices. Any aBermlon or deviation tram above speciticatiorn
al vi
lnvulving extra costs will be executed only upon writton orders, and will become an extra
Si 9 nature �..
anarge over and above the esdrrate. All agreements contingent upon strikes, acc,dentS
or delays beyond our control. Owner to carry fire, tornado and other necessary insurance.
Note: This proposal may be
our workers are lirlly covorod by Wcrkman's Compensation Insurance_
withdrawn by us if not accepted within days
Acceptance III 11roposDl —The above prces, specifications
and conditions are satisfactory and are hereby accepted. )rou are authorized
Signature .
+., rin the work 2s specified. Payment will be made as outlined above.
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Sheet i of
PUTNAM COUNTY DEPARTMENT OF HEALTH
FIELD ACTIVITY REPORT
V {��o�Oc�nr1 COnCaves TPI: 9i'5
Street
Lc-n &° ?v
Town
State
F
PERSON IN CHARGE t L�onAff�� �. Cc
nR TNTFRVTFWFT): OILS
Nam and Title
TYPE OF FACELITY : �r Dc k r
Zip
,511311(
TN4PFCT0R,,, �A � ��U� TFT •
Signature and Title
REPORT RFrFTVFn RY•
I acknowledge receipt of this report: SIGNATURE;
n') /or,
Title-
MEMORY TRANSMISSION REPORT
FILE NUMBER
DATE
TO
DOCUMENT PAGES
START TIME
END TIME
SENT PAGES
108
MAY -13 12:15PM
85268806_
001
MAY -13 12:15PM
MAY -13 12:17PM
001
:TIME-. WW -13- 2011= ._12:17PM
TEL NUMBER 8452787921
NAME ENVIRONMENTAL HEALTH
0
STATUS OK
No completed work is to be bac}rfilled until authonaation to do so nas often oo>ainea from the uapaarznlvni-
FILE NUMBER 108 * ** SUCCESSFUL TX NOT ICE * **
INTERNAL USE ONLY
PUTNAM COUNTY HEALTH pEPARTMENT
o sm l Denied
p�vadV. P�r
E \oFISION OF EN\/IRONMENTAL HEALTH SERVICES
b
L-
PROPQSAL FOR SEWAGE TREATMENT SYSTEM REP^!
i
O Internal Use 40"I
� `Z7
Plepdr Permit I --ee In last 6 years NOt in Watershed
r- iepalr
-
proposal Is in compliance WITH applici ola codes
Q Repair within 9oyd'a Comers, W. Branch or Groton Falls Res. iJ UeiCgated
—/
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[] F4epal, wlthln 200 it- or a watercourse or PEGrnapped wetland (--3 Joint Revtew
SITE LOCATION o .,.--, S ry �•�i r, (/�f TM 0 %rL- / %
PONE
oZ ems.
OWNER'S NAME Vv'c_J:gra F- ei .Jd �_J�ri. GtoKl__RI//e� # S34/��p
MAILING ADORESS 6
APPLIGANT O W �t -�-°a�
Name a Raiatlonsnip (I.e_, owner, tenant, contractor)
//.�� �___
—// FAGILITY�T`YPE Ct�� P(( CHO COMPLAINT
IONF_ IV
..._•.•.�. - - :4ULSf= ii_iy`$ Co !- _,: -rt.P _ _%3yt.�i-- �''t'ltrirslll� -- /ii_t�� FiEGf--TRi+.TIGN'!L'ICENSC'N i'
_ ; is
Proposal (include a saperate sketch locating this house, property lines, all adjacent watts wlthln moo
'
feat of repair and the location 401 axleaing and proposed system)
NOTE= The Department may require submittal of proposal from licensed professional depending on the
nature and extant of the rape r= / !
1, as ovrrlar,agree to the condition -tdia, form�-��
(owner) —T°
!, the septic Installer, agree to comply wtth the con ens of this permit for the septic system repair /
SIGNATURE
(installer)
p Deal app oved with the Tollowino conditions -
7. Procurement of any Town Permit, if applicable.
2. Submission of me befit repair sketch by the saptic system installer within 30 days of the repair. In duplicate, showing:
s_ Ownar's name, Site Stremt Name, Town and Tax Map number
b. Location of installed components Lad to two fixed points
o. System description (e.g., t 2 C
50 gal. onorate septic ffinlc, eta.)
CL Inatallam, Hama and phone number
3_ System repair to be performed In accordance with the above proposal and conditions
4. The proposed SS-FS repair is considered a best fit design and there is no guarantee to the duration mt which the
completed SSTS repair will function.
5.
No completed work is to be bac}rfilled until authonaation to do so nas often oo>ainea from the uapaarznlvni-
INTERNAL USE ONLY
R
o sm l Denied
p�vadV. P�r
G � �
Insp
or's Signature S Title - - - - • d8ta -
-
Expiration Delta,
r- iepalr
-
proposal Is in compliance WITH applici ola codes
Yars
—/
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COPIES: PCHO: Owner; Installer
PC -RP 99iVIL Rev. 2/07