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Home My WebLink About3690DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 74.17 -1 -22 BOX 29 TM I,y16 i�l T � , � � •�� J oil I Is 1 .•1, T , PUTNAM COUNTY HEALTH DEPARTMENT DIVISION OF ENVIRONMENTAL HEALTH SERVICES .' nfC! +6 iR3L"`:C -r'in . TPa�l =L4l -' 6`Vz TIi =AA 0 F: 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 TM # 7`T. l %-% NE # gK-6W C'D 0Wi>1?_V- 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 C7 CP rn cn cn c 0 U c 0 U) c J CL N 0 N C 7 J c i= For Pci v t P LLY-k -s pylk 3 3 P e�L-f +Q, Ta4,,�,) fULb cb.�P-C.41 to E -A— .r 4a / y! �W SZDiLVt�c:- �&-60W,P— e> V +Acx> y- i, l5ck PVC,= u5� X45 A LJ OE-R SO ffp PL) Leo1,L&� 1 4-- So KO-Okj G C�erolyn 17 �^ �Or`��Q -v�-� �- �- v►-DY� 1oSf Jun 20 11 10:42p Leonardi & Son Const. 1- 914 - 736 -9311 p.5 t000 .a�.v b a .. .w _. M. 'I+a. -�_ W ..O i'�_ r�. iy,:><�.i • `�_^.�'++. X34 'i`T ,..� .. s. �. �. ... 4 P T.• ,. _�. �:- �id_i � •.D. ♦l.. i.�... Y'D U4� Pub- i ru t� �-OK I.., C'�Ztp' 96 M-P 1r4 VDU 5 � i i Z A 14� it -ti I2-0 �S- ry Gct ,ro 1p" V r r 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: .... .... .. ................ ..__......._...__..._._._..... ........ . .... .. ........ __ .............. _. _......... _............ ... ..... .__.._..... _.._....._.. .._._......._ .................. Sc°. ier U 3 --------- - - 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. w-, .. � .. . r r., r. _.. a... _ ., .. ,. .. ,. .� . �. .. �. +.:. . .�..F,.�_, .z. vsc .+o+a v � .. __ ... _. . •. ,. _ Si�. '. e'._ _ . :ac..�i .. a I 5 ow-ev; ef Lc�vue J )D- I%TANA'Q. 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 —/ fJ NQ d [] 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 —/ fJ NQ d COPIES: PCHO: Owner; Installer PC -RP 99iVIL Rev. 2/07