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Name & Relationship (i.e., owner, tenant, contractor)
DATE FACILITY TYPE PCHD COMPLAINT #
PROPOSED INSTALLER �&- "m- s PHONE # Q
ADDRESS REGISTRATION /LICENSE #
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.
I, as owner,agree to the o do stated on this form
SIGNATUR TITLE (.��; �,, _ DATE .
.(owner)
wth the condition
s of P ermit for the se P tcs s hem re Pa
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I, the septic instal agree m tf i
SIGNATURE TITLE RIL7—_
DATE ZLT
(installer)
Propgo ARRtMmd 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.
✓ INTERNAL USE ONLY
Proposal Approved Proposal Denied ❑
Ins or's S16naturb & TIN Daj _ /; Expir do Date
Repair proposal is in compliance with applicable codes Yes Q' No O
COPIES: PCHD; Owner; Installer
PC -RP 99ML Rev. 2107
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'`P.GRP.99ML...
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Repair witiunfBoyd's;�Corheis, W'Brar�h"�or GYoton Falls Res ; ,�Y,� ; uD0legStefl ' �,
; iRepair, w�thmr200 �t.rof a�watercourse or DEC�mapped, wetland,_ � 5�� ;�� �Oirlt RBVieW,. ':
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1Name B Relationship (i e, owner, tenartt;rconhactor)u '
l ¢ ; nFACILITY TYPE ; I D— OMPLAINT'#
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paratesk'etch "locating >the house`K ,liriea all adjacaht wolfs witltin� 200
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ocaUon of�ezisting and Proposed x �'
ay�requlreysubmittal�of proposal from licensed professionaldependmg5onathe
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end stated on,this'form:
z x: TITLE t"�� >tit#ti <...: DATE
reedompi with the conditlons of thls`permitfor the septic system repair_
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a!:ollowinacondidons: "
own °. Penmit; if'applk� tile.
repairsketch by the`septic system installer`wiM 30:4 ys .o repair, imdu a'showing
i0keet Name, Town and Tax Map number
d.componencsayed co; two points
1250 O,,. Concrete septic tank, 'etc );
d: phone nut-
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: t :ropasal adcodikxis irfwmd in acordanoewthre awep
low. ;is considered a best fit design and thereiis no guareuiLae'to the tiation at Wiiich.the
ur will. function:'
shoa o 'to so has�been'obbuned from the D®partrnent:
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ANMRMAL U E,ONLY
Proposal Denied ❑
Inspectors Signature �VTPMe :
Date :
Expiratron Date
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COPIES PCHD, Owner, liistal�er
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'`P.GRP.99ML...
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Sheet of
PUTNAM COUNTY DEPARTMENT OF HEALTH
DIV18ION-OF,'ENVWONMENTA17UkAkiLlIf StAVIUS
FIELD ACTIVITY REPORT
NAX4F-:- Tel:
ADDRESS: 01DO
Street Town State zip
PERSON IN CHARGE
ORTNTFRVTPVFTI. 1)q t p5-1/ z
Name and Ti
TYPE OF FACILITY : `�, i ,,, 20- 3 dc"Alal 'S TS
FINDINGS:—
0
Signature and Title
RF.PORT RF.CF.TVF_T)BV,'
I acknowledge receipt of this report: SIGNATURE:
o') /or, Title-
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Signature and Title
RF.PORT RF.CF.TVF_T)BV,'
I acknowledge receipt of this report: SIGNATURE:
o') /or, Title-
.IN-)
PHCWE
Pty aaqplaint
Dame & Relationship (i.e, oaner,tenant, etc.)
TYPE FACILITY
Ott (� ze PHQNE
REGISTRATION # / °
Lgag (include sketch locating all adjacent wells).-
HME: Repair must be in same location and of same type as original serge disposal system.
Different location may require submittal of proposal from licensed professional engineer or
registered architect.
r
Proposal approved jMo— Proposal Disapproved
Inspector's Signature & Title Date
roDosal 4Wroved with the following conditions:
1. Procurement of any Torn permit, if applicable.
2. Submission of as built repair sketch in duplicate showing:
a. Owner's names.
b. Site Street Name, Town and Tax Map number.
c. Location of installed ocimponents tied to two fixed points (e.g.,house corners).
d. System description (e.g., 1250 gat. concrete septic tank, three precast 6' diamo x 6' deep
dxywells 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 re rted a ent of owner agree to the above conditions,
SIGNATURE!Z� TITLE DATE
s Bt'raite LTUD); Yellai (fin W; Pink (ant)
i
May 7, 1991
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DEPARTMENT .OF HEALTH
Division Of Environmental Health Services
110 Old Route Six Center, Carmel, New York 10512
(914) 225 -0310
Louis Nicoletti
Angela Prato
52 Foridan Drive
Putnam Valley, New York 10579
Dear Mr. Nicolett and Ms. Prato
JOHN KARELL Jr., P.E., M.S.
Public Health Director
Re: Nicoletti /Prato
52 Foridan Drive, Putnam Valley, N.Y.
I have received and reviewed the plans for the proposed addition to the above
mentioned residence.
The.plans indicate that the wooden deck will be converted to a screened in porch
1.(aPPr: ,l6'x 11'),
_.
The survey indicates that sufficient area exists to expand or repair the sewage
disposal system, should it become necessary in the future. Therefore, based on
the information submitted, the above mentioned addition is APPROVED with -the
following conditions:
1.Y The total number of bedrooms must remain at two without prior approval by
this Department.
2. The area of the existing sewage disposal system, and its expansion area, must
be maintained.
3. All plumbing fixtures must be replaced or updated with water saving devices,
i.e., low flush toilets, restrictors for shower heads and faucets, etc.
4. The existing septic tank, located under the deck, must remain accessible.
Relocation of the septic tank is not necessary at this time, but eventual
replacement must be outside the porch area.
Approval is granted for sewage disposal only. Any other permits or variances
required are the responsibility of the applicant and the jurisdiction of the Town
of Putnam Valley.
If you have any questions, please contact me at your convenience.
Very truly yours,
William Hedges
Sr. Public Health Sanitarian
WH:pt
cc:Building Inspector (T) PV
BROOK ST.
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VEYED & PREPARED BY
INNEY ASSOCIATES
LANs SI IRVFYnP --
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SURVEY OFRI?OPERTY °
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