The URL can be used to link to this page

Home My WebLink About3742DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 74.19 -2 -6 BOX 29 03742 1 . so IN `` q�16 T' ' w6 . LW `r ` 03742 OWNER'S NAME SITE LOMTION PLTIt1AM COUNTY HEALTH DEPAME TP DIVISION OF ENVIRMWNM HEALTH SERVICES PROPOSAL FM SIIME DISPOSAL SYSTEM REPAIR PHONE MAILING ADDREss P. 0 0 X a 10:53-3-- PERSON INTERVIE{aID l- U1 A- 00 0V,�— •— o w PCHD Canplaint # Name & Relationship (i.e, owner,tenant, etc.) :_ DATE 2. '� CI R TYPE FACILITY H D me, PROPOSED INSTALLER. PHONE REGISTRATION # Proposal (include sketch locating all adjacent wells): NOTE:. Repair must. be in same location and, of same type as. original sewage disposal system. Different location may require, submittal of proposal from licensed professional engineer or registered architect. A RP -- tn.Lac.6l . ivA1ks of-- l zPoit�; GJQrE. do-,& bq oWnor. ter.- �•�s�r.�x�;� 's Proposal Disapproved � �/ z � -, �,- - e::: � _ Date roposal approved with the following conditions: 1. Procurement of any Town permit, if applicable. 2. Submission of as built repair sketch in duplicate showing: a. Owner's name. b. Site Street Name, Town and Tax Map number. c. Location of installed components tied to two fixed points (e.g.,house corners). d. System description (e.g., 1250 gal. concrete septic tank, three precast 6' diam. x 6' deep drywells surrounded by one foot + gravel). e. Installer's name and number. 3. System repair to be performed in accordance with the above proposal and conditions. I, as owner, or reported a ant of owner agree to the above conditions. SI �. TITLE OATS 3 �% ❑ I S: White (PCED); Yellow (fin RE); Pink (AALi®nt) PC -RP 97 t t J /q, 9 u(W OWNER'S NAME PUI'NAM COUNTY HEALTH DEPARTMENT t DIVISION / ) OF HEALTH SERVICES - -- PROPOSAL � FIOR SEWAGE DISPOSAL SYSTEM REPAIR 0 C:f 1, s 1 PHONE SITE LOCATION 13 91 �� Say L � 7 MAILING ADDRESS "� V 7L/= PERSON INTERVIEWED /✓ PcHD complaint # Name & Relationship (i.e, owner,tenant, etc.) DATE TYPE FACILITY PROPOSED INSTALLER C) w ;n e, Y- PHONE REGISTRATION # Proposal (include sketch locating all adjacent wells): NOTE: Repair must be in same location and of same type as original sewage disposal system. Different location may require submittal of proposal from licensed professional engineer or registered architect. c-e Proposal approved Proposal Disapproved Inspector's Signature & Title Da Proposal approved with the following conditions: 1. Procurement of any Town ;permit, if applicable. 2. Submission of as built repair sketch in duplicate showing: a. Owner's name. b. Site Street Name, Town and Tax Map number. c. Location of installed components tied to two fixed points (e.g.,house corners). d. System description (e.g., 1250 gal. concrete septic tank, three precast 6' diam. x 6' deep drywells surrounded by one foot + gravel). e. Installer's name and number. 3. System repair to be performed in accordance with the above proposal and conditions. I, as owner,,or,reported ageaat of owner agree to the above conditions. SIGNATURE IPgS: Hihite (FW); Yellow (fin SU; Pink (Apl.icc:t.) PC -RP 97 TITLE DATE 31kl ?y PUTNAM COUNTY DEPARTMENT OF HEALTH z DIVISION OF ENVIRONMENTAL HEALTH SERVICES INITIAL INDIVUDAL ADDITION/REPAIR FORM SECTION A: GENERAL INFORMATION Name of Project P( (T)(V) TM# Year of Construction Size of Parcel 2 SECTION B. TOPOGRAPHY (Please check all appropriate boxes) 1. UHilly ®Rolling ®Steep Slope ®Gentle Slope []Flat 2. ®Evidence of wetland []Low area subject to flooding ®Bodies of water ®Drainage ditches ®Rock outcrop YYEES/ NO I Property lines .evident? l� 4. 'Water courses exist on, or adjacent to parcel: 1� 5. Existing individual wells within 200ft of the existing SSTS? LL SECTION C. EXISTING SUBSURFACE SEWAGE TREATMENT SYSTEM(SSTS) 1. Physical character of existing SSTS area. A. ®Level UGentle Slope e P slope �� B. ®Well drained l�Moderately well drained ®Somewhat poorly drained ®Poorly drained C. Area available for SSTS. (Primary & Reserve) �� ®Extremely limited ® L* Somewhat limited Adequate _ft x ft ,1 -.§.R D. INSPECTION Date 3 Inspector„ ONo evidence of failure: L1Evidence of failure ❑Evidence of seasonal failure vl 9 Cn m m ------- - - - - -- Q-- - — ---=---------------------=---------------------------------------- (Indicate North) (1) Indicate location of SSTS A. Size and type of septic tank Metal Cloncrete B. Type of absorption area 1. Fields ft. 2. Pits gallons OPlastic 3. Gallies ft. -,.. ..._.,.(2) Indicate setback's, ..c:il street; backyard, and sd yaru',airnersicns _ (3) Show location of well (4) Show location of driveway (5) Note physical features (steep slopes, rock outcrops, streams /wetlands) SECTION E. EXISTING WATER SUPPLY DPWS CIShared well Ofndividual well 01-51r�illed ❑Du; L- Casing above ground b U COi NTS : REPAIRS ONLY: Status: As Built Inspection Required: As Built Submitted: As Built Inspection Done: Inspector: (addrep) PUTNAM COUNTY DEPARTMENT OF HEALTH c-mplaint NO. 523-98-19 COMPLAINT OR SERVICE REQUEST RECORD � '" fff TOWN "Putnam DATE TAKEN BY BH TELEPHONE. x -CALL IN PERSON. LETTER. CONFIDENTIAL REQUEST FROM Mahoany PV ZBA ADDRESS . Putnam Valley TELEPHONE 526-2377 ENVIRONMENTAL HEALTH: Sewage Nuisance Public Health Nuisance — -- Chemical Emergency Individual Water Other COMPLAINT OR REQUEST 13 Bluejay Place off Wood Street, has open septic tank and pipe discharging to the surface. ACTION TAKEN BY lq� L, L(,-t,L DATE �dz iL w FINDINGS gi-e LA c s lJ C-0— L ri!;, 0 1 / -7�1 - - v 7-2-1 , 5- I'll a- / 11A, V A h I A � r, 01 ea , 1-42, -S,, , I/ FOLLCIl.UR INSPECTION bkTt FINDINGS DATE FINrYENGS, PROBLEM ABATED DATE PERSON NOTIFIED ESTIMATED TOTAL MAN HOURS SPENT PC-CR 97 PUTNAM COUNTY HEALTH DEPARtTMERr DIVISION -oF ENVIRONMENTAL, HEALTH SwICES - - - � ; PROPOSAL FM SEDGE DISPOSAL SYSTEM REPAIR p� OWNER'S NAME L u. } � A • j) ,,t Q SITE IDCATIoN 13 3) U e_ MAU, M ADDRESS P. 0 6 O X WOM 105 PHONE 9 W) S Z8 �IqO Z PERSON uii Do ov,�_ PC HD Conqplaint # Name & Relationship (i.e, owner,tenant, etc.) i DATE – — C'I ?� TYPE FACILITY H c) MPOSED INsTmim. PHONE REGISTRATION # Proposal (include sketch locating all adjacent wells): NOTE: Repair must be in same location and of same type as original sewage disposal system. Different location may require submittal of proposal fram'licensed professional engineer or registered architect. L_06%,� d RP --tnLUYCeA. 'Wails o.- �0rr. � J ClQ,nC` e AI 17e.s S we "C. d Proposal Disapproved ��/ 3 / I Date proposal approved with the following conditions: 1. Procurement of any Town permit, if applicable. 2. Submission of.as built repair sketch in duplicate showing: a. Owner's name. b. Site Street Name, Town and Tax Map number. c. Location of installed oomponents tied to two fixed points (e.g.,house corners). d. System description (e.g., 1250 gal. concrete septic tank, three precast 6' diam. x 6' deep drywells, surrounded by one foot + gravel). e. Installer's name and number. 3. System repair to be performed in accordance with the above proposal and conditions. I, as owner, or reported a ent of owner agree to the above conditions. SiG _ TITLE ) ( o Yl.� (1 a.i'E S� .J_ 3 [9? ]IT 5: i+iiiite (KID): Ye]1va (fin HI); Pink Vglicant)