The URL can be used to link to this page

Home My WebLink About3812DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 83.12 -1 -32 BOX 30 INNS I,yti ' W ,% I ,� I T 91 1` f ,tit .' �: 1' LL a 03812 i PLTTNAM COUNTY HEALTH DEPARn4W DIVISIO[J OF ENvIRONMENIAL. HEALTH SERVICES- PROPOSAL FOR SEWAGE DISPOSAL SYSTEM REPAIR OWNER'S NAME M IC %oL\ ; .;Any PHONE SITE LOCATION rP TO � zT) MAILING ADDRESS 4�� 11U �• r . ,� H PERSON INTERVIEWED PAID Canq:laint # Name & Relationship (i.e, owner,tenant, etc.) DATE TYPE FACILITY itts - PROPOSED INSTALUR () � i t PHONE ;J c-L S'- - 7 6 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 I registered architect. /^� ^^ / ``,, `` r `` meal AtInikiONAt $+ Salh6< (2NaiHuAa. 6r a et.Q<1l.rro[ AA,- l- f' -14AMt -4 +gtr vs cetr1cc.- jai samt 4ro+� m T Ni4t R Proposal approved Inspector Proposal Disapproved proposal approved with the following conditions: 1. Procurement of any Town permit, if applicable. 2. Surmission 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 agent of owner agree to the above conditions. SIGNATURE TITZ.E PI6: *ate (PAD); Yellow (fin ED; Pink (Afpl.ia wk) DATE C 0- PUTNAM COUNTY HEALTH DEPARTMENT DIVISION OF ENVIRAL HEALTH SERVICES ..225-0310, ��y�2�AI� CANER' S NAM a (' -V% L1 L iA t.l C j- i -4, i ArO PHONE SITE NATION ,Yet. R5 < 5z _ _ 1?f - ,''zy_ p AOS ghA [.r -1yNA\ TO MAILING ADDRESS r 7,2 PERSON INTERVIEWED MiL ��1�,c��.1 nkA.. -�R_Y" JL //, PCHD Camplaint # Name & Relationship (i.e, owner, t, etc.) DATE 15 5 f TYPE FACILITY PROPOSED INSTALLER PHONE 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. r n j % ,54t-,J ,,. i av`. i , tip• r � � v. � v .�,� v i c ;t i ".rlcwtAt alc e Xks3A<, AAy 39 V z%V ICY ° {Q. , l ,L u 3-e *° o Proposal. approved ,X Inspector' s .9-i gnature Proposal Disapproved Date Iroposal approved with the following conditions: 1. Procurement of any Town permit, if applicable. 2. Subzmission 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 61 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 agent of owner agree to the above conditions. SIGNATi]RE a TITLE �wr.va�,c.�cti� DATE j�'�r.H S° lc5-4 0PBS: V&te (PCHD); YeUc w Mkn BI); Pink Lk#imnt) O .. PUTNAM COUNTY HEALTH DEPARTMENT DIVISION OF ENVIRONMENTAL HEALTH SERVICES SEW AGS`T-PCEAMENTt YES MO Internal Use Only PERMIT # - ❑ IL9f epair Permit issued in last 5 years ❑ blot in Watershed ` ❑ Repair within Boyd's Comers, W.'. Branch or Croton Falls Res. Delegated El Repair within 200 ft. of a watercourse or DEC - mapped wetland ❑ Joint Review /_ _ SITE LOCATION f'Z C WIV J. V� jC�yy1 TM # OWNER'S NAME A4 t kli ' dt>° PHONE # MAILING ADDRESS S OSC A W A! A, APPLICANT LQG0,L 6LJ4 C J Ww / (,, Name & Relatio ship (i.e., owner, tenant, contractor) DATE q /JA3 b FACILITY TYPE 3 !' M� PCHD COMPLAINT # � 0 PROPOSED INSTALLER L ociod 6 U'j P)i4ftyalvJG PHONE # pVY !N ADDRESS 3 rl✓y&"- REGISTRATION /LICENSE # / o)'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 na re and extent of thW�� ir. ,y 19 �w � � c ),.J % Ar X U i Irk.A 7Z1—d 'L l- C,rl.vr I, as owner,agree t dit' stated on this form SIGNATURE TITLE OWX-N�V'Z DATE I, the s y aller, ee to comply with the conditions of this permit for the septic system repair SIGNATURE TITLE DATE 3 O (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. 114TERNAL USE ONLY Proposal Approved a Proposal Denied ❑ Signature & Title Date Expiration Date is in compliance with applicable codes Yes ❑ No COPIES: PCHD; Owner; Installer PC -RP 99ML Rev. 2/07 Sheet t of�_ PUTNAM COUNTY DEPARTMENT OF HEALTH • o: �i• I'. ��' IaS T�; N,' OF': I; 1` 1, Y. �it�. il', Tll af�ns�. 4:> <;r..��'��Ia�r��Vj�S.::.. -.... a ,.e, _..... _.:�: - ., _ _.. FIELD ACTIVITY REPORT N n �� • ,� /7ri�i/1�t1 Tel: 8.9s — 5 lr — 8 7 'fo Street Town State Zip PERSON IN CHARGE (1R TNTFRyTFwFn. . M/GG.401—Z 4/a'' L' A4 P6�� . Name and Title TYPE OF FACILITY: SI.vIL s a� /L�/ dui GU�tiG S S '� `- zaP"yzz t TVT . Signature and Title REPORT RF ^FT FT' TAY: I acknowledge receipt of this report: SIGNATURE; 02/96 Title; .I PUTNAM COUNTY HEALTH DEPARTMENT DIVISION OF ENVIRONMENTAL HEALTH SERVICES 7_7 - 11-KQPOSAL� POKSE WAG -E TREAMEWil f-MM3WWFft`- Internal Use Only PERMIT # r,, - Repair Permit issued In last 5 years ❑ _Pot in Watershed 0 "Repair within Boyd's Corners, W. Branch or Croton Falls Res. a Delegated ❑ ID/ ReDal-F-w—Rhin. ?-OQ ft. ,of ,a YvWe"rse or DEC-maoDed wetland ❑ Joint Review SITE LOCATION i TOWN TM # tv OWNER'S NAME J. 14 PHONE #`, MAILING ADDRESS f S�-j 1:)-&C,! u, i t rtir rrs C V J ti 6 Ax],-)t L) fri� 1 �Vz APPLICANT Name Relatiorfship (i.e., owner, tenant, contractor) " 3 Z DATE j i FACILITY TYPE PCHD COMPLAINT # PROPOSED INSTALLER L b PHONE# y � ADDRESS 4IAta� 4, REGISTRATION /LICENSE # I 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 rep In 2 , -k. -<J1 1.'V'1 i I ,A I �'�.'v'+•--J (,,S• / (fl r..ji 1, as owner,agree to the(doInditib/n§ stated on this form SIGNATURE TITLE' DATE (owner) I, the septic installer, , SIGNATURE iY ,�J*'!,(,\ TITLE piiA-6-,t. DATE 7 1 A I 1:J (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 bed 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. INTERNAL USE ONLY Proposal Approved Proposal Denied ❑ Inspector's Signature& Title Date Expiration Date Reoair oroDosa,Lis-in e6ni liance with aoDlicable codes Yes 0 No Z COPIES: PCHD; Owner; Installer PC-RP 99ML Rev. 2/07 Ao 0 7SS'16 :./A 0 Li. i-. troy c ........ ...... . V,tx-j ki 71 L-11 rV4 IP q3c i(q( q7(i :./A 0 Li. i-. troy c ........ ...... . V,tx-j ki 71 L-11 rV4 IP t 1 O P" ai ;t A 9 t: is cyi eke • f r cr 5fo � ` � 5fo�e cSfc4•e r u. ke ' � it/oo Biz Fcnc G V ,' N6G ,�D 1t/ s 2 .2S p4 Al' r- is i! i• . :t 4 t �9 tj .F ensue c5 ° 00' 0 0'" 0 7,;�q 4` q 0 c ttvcco ,yovse - C*r,`C-o Sl 3 os - /(/oo en Fenc � �4J It