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HomeMy WebLinkAbout3721DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 74.17 -1 -78 BOX 29 03721 PUTNAM COUNTY HEALTH DEPARTMENT DIVISION OF ENVIRONMENTAL HEALTH SERVICES PR POSAL FO f3 SEWAGE TREATMENT SYSTEM REPAI vF� N Internal Use Only PERMIT # . Repair Permit issued in last 5 years LJ ^t in Watershed p1� EI Repair within Boyd's Corners, W. Branch or Croton Falls Res. 20' Delegated Repair within 200 ft. of a watercourse or DEC- mapped wetland ❑ Joirl Review SITE LOCATION TOWN LW TM #% OWNER'S NAME STU PHONE# MAILING ADDRESS 2 �.,j, I, �Tawe ,n ���►e@•� V�(Qy APPLICANT .s_� v >XC�L' c Name & Relationship (i.e., owner, tens c trac DATE FACILITY TYPE PCHD COMPLAINT # evio PROPOSED INSTALLERiP�GltJ CXCc., PHONE # �Ys�z� enZy ADDRESS �/'' /3v�.1_�eT�� REGISTRATION /LICENSE # / 2 IZ5 3 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 nature and extent of the repair. • Ti5/li�E� �C�CcPS © Z- Alm /GT.rQ.4�TdKS 4T 1FlY Z­A OAK-Y sf//TH «.dUFiL�. • / 2 So Ci4G. S € ?Tic 2-AAJ,u . • 17iSTr`Y /13/�Y /oilJ LioK� . I, as owner,agree to the conditions stated on this form SIGNATURE (owner) / septic.instat;et,_-agrr( TITLE 5'1 clvr -1 DATE Z U ply with the. cpnditia_ns of this.,permit_for.tt,eaeplic oe 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 completed SSTS repair will function. 5. No completed work is to be backfilled until authorization to do so has been obtained from the Department. Ia1 ;q;U W Weic -ML,t,1 Proposal Approved Proposal Denied ❑ Inspector's SiglTature & Title DEfte Expiratioli Date Repair proposal is in compliance with applicable codes Yes Q' No ❑ COPIES: PCHD; Owner; Installer PC -RP 99ML Rev. 2/07 I e: In i Ci k4 J PIt (!t I I i I e I RA o I 1� k i s' to s E Ds I I I �� ,� ►► �o j IL qAJ I i I ' I I I ' LG Q� t 4-L, f IVJ /7 0 5 vnc7 awe VdPt4 V"VA same LA ke // Of J-9* WA40.L ry f'floviaig J-Arn7 7)14 ke // Of J-9* WA40.L 3Nt/7 x0oafiff f'floviaig J-Arn7 7)14 'A A Vo J.9' ki t —ftrbi % Os rN, IPW►dt o 3Nt/7 x0oafiff � ; g�t��� '� Sheet Hof ���������gg ((�� ��, � - yPU�TN:�.M,t�''®U�T.T�' DF�P.��t�'ME�1� �UF H�EAI.�'�Fi � -- �.. i�i'WPl.4 .... .. 1 ?i ..t. .,.. .. ...v "yly ,4: �F: �1 _ �:. :�:.�,�___ �'._,._� { ���.�..�'�'.�'.A _.. i-. .... .. ... ! � ` 14 F � � �:1 ; ti I XT-i5-00T 03:47PM FROM-ENV I RLINMENTAI HEALTH SHERLITA AMER, MO. MS, FAAP %74 commissioner of Health LORETTA NIOUNARI. RN, MSN 8462187821 T-814 P.NZ /002 f -386 ROBERT J. HONDI ?♦ Carroll F.x'reottre ROSE Px- 1Jirevsor of Fnvipasomenlal He4uh DEPARTMENT OF HEALTH 1 Geneva Road, Brewster. New York; ; 0509 0_UF,Sr ,off D T- FSTING A.1; information below must be k1tv completed prior to any scheduling. .DATE: g !t', 0'f ENGINEER OR FIRM•:21 ���/ �>oG �� PHONE PEI{.SON TO COtiTACT:; ,-7— c>7"__� CONSTRUCTION 0 REPAIR PROGRAM 0 ADDITION PROGRAM REASON: DEEPS:.9 PERCS: ❑ PUMP TEST: Cl ROAD/STREET STSrw P_'•G TOWN__._ �? 1� �►r TAX MAP SC>t131DIVISION: _ LOT #:__„ 1-'S tO631•CRITERIA FOR JOINT REVIEW AND Wit E 'SZNG_OF SOYi T1fiS'LING Yl~5, NO -95:p Proposed SSTS within the drainage basin of West Branch or Boyds Corner d: Groton •Fails Reservoirs. ?a' Proposed SSTS within Soo, feed ofa reservoir, reservoir stem or control lake. r- Proposed SSTS,within TOa1'eeA of a watercourse or a DEC wetland. err- *:Q Proposed 9S'TS'de3lgn flove' grasper than 1000 Sallonsiday or. SPDES Permit required. Fropbse d SS'TS for ' Commerc _ m jc ee It is the responsibility of the design professional to provide the above information prior to soil testing. The Department will determine the TWCDEP project status (Joint or Delegated) b:ascd on the response. If you anstwered,Pes to. any of the questions, NYCDEP must witness the soli rests. This bepartincat wilt 0ordinate a mutually suitable time for fleld,testing with the Design Professional and NxCDXP. It a project 'khs been determ zed To be Delegated based on the above response and then subsequent information indicates SYCDEP:k required to witness the soil tests, it will be the sole responsi6lilty of the design professional, to _"bedult re- witnessing of the soil tes du; with NYCDEP. FOR COUNTY USC ONLY -� nwsl�:�_a` TrnaE! COiv�MF:ivrs: '16Q "DO2 ►ce.� +'e:rw0'KY &avirpa"WAMl NnaltA (SA S)278 -+613C Fax (245)37R.^0_] Water Suppiy Section (945) 325 -5186 Fax (845) 215.3418 Nursing 5crvicsa.(845) 278.6558 Fux (845) 278.6026 WIC (843) 27'8.6678 Nursing Home Cart Fax (845) 2784W5 �% / � Early Ieprveasiorrlhesehool (it45) i78.60I4 FaK ($4S1 ?78 -648 - - -.G s I ! et AUWAr I g I o i RD i w i 4 Q es\ ki m !. $ :20 1 L. R .SCaVlffa�i� 1 3 . \y rm Corn �= i o Bryant S �u . won }, t N NEADp�, ° pq iA 1.05 79 F f� ar 4u CN \ i; pr's ° J a g 6E r4 ° u S � i ° J a � ir!N E DR I llNOwu D� i 1 qt vAnmio°e 4 aocN 6__, _ za I 4 ° - �+ 22 aPon: surntwu ►"' "y gLLE JAY R 1Y �p 1EA ° m m p_. v AD \ � R m I •fa IS ATE:. m useum \ . i Corners T % TE ose Hill Park o� D^a_v►d C x r 'em c c OR j 23 "° Lawsoo Cem g LP, icn � wow s� WLL PON'O� '%, 6MRN .p 9 211 \4 ��� ®u EAST STr-""/ BrooO RU rub sk r4 rsa s'N V Hey MER St .EXT B (UNOPENEO� BROOK LANE DUE. iVCSRr.N —:r I. . snare •� - , , _. ..-,. � _ ,. - - ...._ ••.,... .e-.r . 4 �o p 4�i ! h Q. e V fav I O w p ' ; p subsequent Bank, rifle Co. or Owners BROUGHT TO DATE O GN�aGe h map and t6 thereof olds if said map er JOHN SALVATORE ROMEO ,, • � e{ brdar +he improved seal of the ser- N S.o...j STOKr l ' I NORTHRIDGE ROAD :'' . y ya is h�y�y� *fled that this wive y was f rwK V' sN •� I "LNt�7. a/O�Mij P. E. B L. 5. NYS LIC. NO. 02784611 • /... . ►dlla Steveyors • . I 1 1 1 Os'6.r h . 3I Q srwre iLr 4 �o p 4�i ! h Q. e V fav I O i ae, c7' I W' , sr...a .T"j 08.44 f rwta sar P i h \ a V) t l • +1. N 4F� OUE SCUT /� -. j' Pq -CCEC tv° /o CERTIFIED TO- t o v „a 4 218.50 "P,e4e /SE.3 .sNOWU HEREON @E /N6 PA[CEt me q3 ji40Wiv ON MAP, E/VTrTLEd "MiiP N21-64ENOAOOK Sq /D a4,4P f /LED IN THE OFF /CE" OF TNe GoVNTr . CLB.e2' OF Pe/TNAM” C0uNrr, CgeME4. N. Y. ,9.f MAP /YT 480 ,yevlM6ds /z, X992 Certifications hereon are vsGd for Beek, SURVEYED: Title Co. 8 Owners for this transaction FCAM[. ; ee.ra weu. subsequent Bank, rifle Co. or Owners BROUGHT TO DATE STUARr r �15cj -jt e.rR GN�aGe map and t6 thereof olds if said map er JOHN SALVATORE ROMEO ,, • � e{ brdar +he improved seal of the ser- SITUATE IN THE S.o...j STOKr TOWM Of P&r"AM VACCEr I NORTHRIDGE ROAD :'' . y ya is h�y�y� *fled that this wive y was Pl/T/VAM COUNTY FRAldE C. NEW YORK "LNt�7. a/O�Mij P. E. B L. 5. NYS LIC. NO. 02784611 • /... . ►dlla Steveyors • . I 1 Os'6.r i ae, c7' I W' , sr...a .T"j 08.44 f rwta sar P i h \ a V) t l • +1. N 4F� OUE SCUT /� -. j' Pq -CCEC tv° /o CERTIFIED TO- t o v „a 4 218.50 "P,e4e /SE.3 .sNOWU HEREON @E /N6 PA[CEt me q3 ji40Wiv ON MAP, E/VTrTLEd "MiiP N21-64ENOAOOK Sq /D a4,4P f /LED IN THE OFF /CE" OF TNe GoVNTr . CLB.e2' OF Pe/TNAM” C0uNrr, CgeME4. N. Y. ,9.f MAP /YT 480 ,yevlM6ds /z, X992 Certifications hereon are vsGd for Beek, SURVEYED: Title Co. 8 Owners for this transaction SURVEY OF PROPERTY BROUGHT TO DATE )9Pir6 L8 / 9A3 only. Certifications are not transferable to FOR subsequent Bank, rifle Co. or Owners BROUGHT TO DATE STUARr r �15cj -jt e.rR AB certifications hereon are valid for this map and t6 thereof olds if said map er JOHN SALVATORE ROMEO ,, • � e{ brdar +he improved seal of the ser- SITUATE IN THE • , Gmndring Engmea :. Land ;umevor nature appears he 9 R1° reon. ,.'.`' , r•1y"If TOWM Of P&r"AM VACCEr I NORTHRIDGE ROAD :'' . y ya is h�y�y� *fled that this wive y was Pl/T/VAM COUNTY PEEKSKILL. N. Y. t` prap`?ed ii. accordance vnfh-the existing Ca;4of Vf4cfife for Land Surveys adopted a� +� NEW YORK t . by 46 :,i`.sr;;I'•prk State Association of Pro. P. E. B L. 5. NYS LIC. NO. 02784611 • /... . ►dlla Steveyors • . I SCALE: f 3e 100.00 i i moo 150.00. el y� 0 � FIELDSTONE ROAD 20aoo ao I A n `n j fn — 1.25 AC. CAL. 05,77 f 9 o I 1.00 X CAL ro �� I� iv 37 34 z co G 6 ,I; 1.25 AC. i f ( G9 J� 1 250.00 14.70 AC. / SLATE OPEN SPACE '• % 1 ro: 35 i O 36 Ji 1.00 AC. s •` .I AC. 200.00 300.00 I . CROSSING 200.00 150.00 150.00 ill A P :3 55 w 7 r - . S 1.00 AC. 100.00 i i moo 150.00. ROAD 20aoo ao n fn 1.00 AU. CAL. o I 1.00 X CAL ro �� I� iv 37 z co 6 ,I; Its 1 AC. ;t` 1 ro: 35 i 36 1.00 AC. 11 •` .I AC. 200.00 300.00 I . CROSSING 200.00 150.00 150.00 A P 55 w o S S 1.00 AC. 45 44 m 0 cn • . m 1.00 AC. F 1.00 AC. .p 1 150.00 150.00 54 1.0 AC. ! s 43 1 T = /OO' 7-