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HomeMy WebLinkAbout3904DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 83.16 -1 -47 BOX 30 � L ■ 1 . • 1 rL� ti -,F r , 1 1 1 03904 3/4/2009 6:01 AM FROM: Fax TO: 845 -528 -8175 PAGE: 002 OF 002 PUrNAM COUNTY HEALTH DEPARTMENT DIVlS10N OF ENWRONMENTAL HEALTH SERWES PROPOSAL FOR SEWAGE Z'REAT�IENT J1t 51f5i R YM No mifafnal fuse aniv PERtAiTdf E_3 0 f if tamed a► s yeas U N t h Wammtod CJ U +rUOm+8opfsGanes vrr.t3ranasaG?aoonEstes Q Debated SrtE LQCAT4OAl TE3W v�✓�u o ( T>Vi i OWNER S NAME At, n PF{4NE . r�C - MAIUNG ADDRESS 3 Y CD l i /t f 6 e c 1+d APPLICANT A19eg8 b li.�.awnar, �. ooe� DATE FACIt NTYPE PC14a C,OMPt AIW s PROPOSED 04TAf.LER v` t` ,,,� C� g I , `� ,' Pttaw- a ci ! 5/ Y1K ADDRESS J `yr,.b A4 J1' P ,U REGI51MATIMI'IUCENSE At z L emosd (irtdude a sepeiale siwtth tacdmg the houst properly liter as atdfacaft was vMwn 200 feet of rspdr atop the loaffon CA eitisiing PW poposal ey ottim) . NOTE- The OeWMM nnay require suWndW of Wnpnsal fmm fiord profesaWnW Bewdtng on the nature and ext"t at the repair, I. as OwrwAgree to the cm 6 tWm stated an ttsis font StONATURE T}TLE DATE 1. the septic irk, agree W o0afpty arith ffha mndiriatrs of ttds pemtit far sep SP MM repair St %NATUAE TITt E (,f s Ou�TE J. prammusm of arty Tonne Perrok I appl[mbte. I 2 SobmaWn of as txrfb repair sttWMh by tee aePfic system aierassr Wk1 M 30 days arms repair, at st�nain� a. owners rteme. Site Sow Mame, Town ant Tex MW Diner i. b. Location of uvoaled campmwmm tied m uxo tired pc§#s �._..._t. .'� - _.. t.. Syrt9a+ e( e_ 9-• t�.�..ea�sra�s�setsnk..ert =_.._ :.._...,_. ... .. . _ ._.. ._ _... -. -. _. _. _.._._.. �._._ .. j d. Gutetfane rwi m ant pfwm number I 9. S,yste. * * be O in deep wit* vAft dw above proposal and midloon 4. The proposed SSTS mp& is aonsiftiod a tress f$ 4=4p and Uwe is na wee to ttra duration of whk* the a n 0amd 5575 TgMfr WE kawom 5. tVa mmn�tad ozarlc is to he t> ura &desire► w da so has bean obt *W from 'he . Pmt AWOved ❑ Propow Danied ❑ Inspectes Qv- ature Tw— Date Expiratian Date s is in comeMn with 9jow0le wades Ye$ No 13 COPIES: PC HD,. Owner . irtB oer PC -AP 89ML Rev. 2107 - oUIX -R-I* - C-7 -- A TRUCTION -PORAWO 34 Columbus AVeliutnAr� -Valley N-.Y'::10579 914-760 6344" N. Alison Scott TM 83.16 Block I Lot 47 Date 3/11/09 28 Brookdale Road Putnam Valley N.Y. 10579 A 1 13.0 B 1 16.0 A2 21:0 B 2 18.6 A 3 219.0 B 3 36.6 * 4 310 B 4 37.0 * 5 36.0 B 5 36-6 'J O O License #- 1137 Septic repair 0 Sheet — of PUTNAM COUNTY DEPARTMENT OF HEALTH ..-IDI-YJ$14DN.--OF -ENVIRONMENTAL HEATLH SER. -qES FIELD ACTIVITY REPORT NAME' C- 0 l '1 Tel. ADDRES,q: ;-Z SIZ00iShALE 112D, *, JII'WM V,4,14,6K4 /dy, Street Town State Zip PERSON IN CHARGE nRTNTFRVTF.VJFM avAL,7-1,01?l 60AZSZ. Name and Title TYPE OF FACELITY: -S,s7rs, -ZEP-4177 FINDINGS: W&SLI lk &4 vaw A0 yf- pute-6,2�s �J •6lc- 46 k vg/-.o- 4s� 1,e G ao-s 4u id In I e- IL4 4 Signature and Title RF.PC)RT RFC F.TVF-T) RV: I acknowledge receipt of this report: SIGNATURE: 02/96 Title: 'P.- 3/4/2009 6:07 AH FROM: Fax T0: 845 -528 -9175 PAGE: 002 OF 002 PUTNAM COUNTY HEALTH DEPARTMENT DIVISION OF ENVIRONMENTAL HEAL,TH.SERVICES tit osm t' S±t:V9f VliifF /11R _ •f PfenM ienued iAlm Slams L.�/t� TI! Y!f al Retmi am swfTs Ci WAW. W. w wm cromm. rte: a. 13 ityooir "Vim Mot td a eomo as aroso4manduddWA Q Jot{i RwA SITE LOCATION p � .r TA f�Ue 1 � OWNER'S NIMBI= ,� (�' S �. i S p Pl•IONE d�. MAtUNG ADORM 3 A o APPucANT V L (:212 N-W A Roman" Qs. aww. teaaont a A DATE �f FAOUT`� TYK PcHo COtitltftmW, o PROPOSED INSTAt.t.ExR U J C9 c+ g f F. `� f .' PHONE a l y -7t/,'O ADDAM 3;lC l�.ub�s �Jr, .tl. rSTPAIVNILECENSEo '? Qfnaude a ,oepeeate skate* mcom ft ttotm. Woo ft ww% as mWaft arms utfttM 200 feet of repstr aid the fo=am of a"ng and pmpwad op mt) NOTE. The OOPOMTWR st+tay mquire'submtital of ptopow imm load prod deftwino oo the notume and em pt of the repair. } / f r f� c_b 4• �`G y ` � . L as owner agree to me cot mom stated on this form SIGNATURE 71Tt.E O (strtvnesr) . I, the sceptic islito6v. 801" tD ,cimpty sidle we as moom of Rft pffm for t o sapdc *=m few SIGNATURE Tf7u le s DATE--% T�- S. Prosxusmstn[ of any Taws Penok d spoffift. 2. Subu*don of as twit mpak Aemh by the step c siyateal rdle2m vAM 304M of ft Mpair, M sit"nW a Owrwrs name. Sim Street Name. Taws and Tax tessp mome • U.. Cocos of kuow Od eomponmm OW to ,=ffmd pots E. :t'� ��CY�-9oei ie.g.; t°sa0 gal: 4'bKYa�! Oepdt talllt, �ej d. testftW dame and phew wabw 9. System sq ew to be, in assexmns:e wtettt0 mom poposm am oord&M 4. The p►oposed SSTS repefr m anttltdored a beet etduip wd dwe is re @Wmhm to toe dusstIm et wldetrMe BoR1oRmw ssi T$ rapolf wit an>t,tm S. No =mpmrod ask Ia to he 4aet:eated w+6r atfasorisragm w do So has bear► obmised ham the Depwbrvrfl. *frL Nft U8f ONLY txrapaeta! ovstid Ptopesat Dortwd ❑ \ 7 � ttsoachy's Signature A Tw a Ex0foon date COPIES: PCHO; Owner; Imalter PG-RP 99ML Rev. 2ID7 7� 6 3 YlK JUL-10 -2008 13:49 FROM:FISCAL 8452786112 70:94529122 P:1/1 PUTNAM coui4TY"viEALt"H'b*E'P"*A"k"TMENT DIVISION OF ENVIRONMENTAL HEALTH SERVICES THIS IS NOT A REPAIR PERMIT PROPOSAL FOR EXPLORATION OF SEPTIC SYSTEM FAILURE All Information below must be fully completed prior to any scheduling SITE LOCATION 6r,%) J-< Jet /r TOWN j (A& TM# OWNER'S NAME PWONE# MAILING ADDRESS Pe- I,,- PROPOSED CONTRACTOR/INSTALLER G v0. ty-) e-LL PHONE # IF-II/ YY -'e-q-t -140 P T L.-,.t ADDRESS GIS TRATION /LICENSE# //2 Reason for exploratloj]:, 0 failure to surface 0, back-up In house 0 find Hmfts of system for repair IZI other (explain below) Date: Time kly,excel:septic Date ,t/ ,61 (0 C-) 16M A "In.19 -sop lW(W, TANKS BOOM PITS OIL ATS :I.NDUSTMAt-S.LUIM. ---------- - W -,- ANY TOWN .01Z STATE K. X UIYZ & SONS 4. " it d lAo. Nim I LAW.Peakokk K -Y.... 71 'N U155 POOLS (NSTAMD• -C& Dm kANts VI ta p 3 <4- t�J�fF BROOKDALE GARpEN.S. ING A - e :Y.:_ *- c': --•y .. r :. r .,... C • .p -i rn L-P. .' qyL. A 0 'To- r S v fif"? g :� .. '4"x.83' ''.c•cQ F ;' _ •k �� Dp `00 . . s o � +a .peg � � ;`�'� � •� ,$ 4 ,C*d £xi5�:a9 Corso. °i^ ' Seel ge- Pit k,To lv� A( Qe C,ro PARCEL SHOWN VtERIEQN REFERENCED HY',01ttO. RECORDED LN THE PUTNAM COVNTY CLERK'S OFFICE TN USER . 30 OF DEEDS AT PAGE 1'9$ Si10,IECT TO ELECTRIC AND/OR TELEPHONE TELEPHONE CO. CASEMENTS, IF ANY, FOR OVERHEAD AND /OR, UFMER^,ROUMD SERVICE SURL €'Fgl AS IN POSSCSSIC✓•I, (NO LMB6 of Po"bssidf an lv 7,»n ,fn dices t@O). SURSMUCrJRtES .AND /GR Ta Clk ENCODA64MENTS BELOW CRAOE, W ANY, NOT SHOttlbt, -INOSE OFFSETS TAKEN TO SIDING OR MIk PROPEP I-r CORNERS NOT 'STAKED. T fropose� l%Tsffi�Irr:oe So)( Propa�Se aLQ oLTOFt INN V t CER FIFiCATIQNS INDICATED NEREf'1a!1 51.OTIIPV THAT ?MI SORVEY WAS QHSPARED IN ACCdRDANOIL WTH THE . SkISTING CC*E OF PRACTTCE'P'OR LAND- SUR�S'Y9` e \ AOOPi1E0 BY THE MEIN YDRIC'STATE AFiSOC1AT(ON tW PRO"_ —.0NAL LAND SUR%MYORB. SAO C@RTYFi0ATT0P, / SHALL RUO dM-% TO THE 'P9R50N8., 0OR VNi Q_M. TIME. f[6�� RwEV IS PREPAPED AP40 ON TNETR B6NA�C' 10: i TITLE COMPANY; GOtIUWMENTAL A.GErfCY AM. I."M TUTION LASTED MEREON. ANO ;rd N '- G1�oh. '4ntr t<nsa G9tvClly :1.2' S°Utn .e/ LAIi.°•+� t t SUB«OUENT OrlN[RS -M �-s�AA>� PV.TN PtLR COUNTY, f. N. . SURVEY OF PROPERTY IN. gym. as cap.o lna P1 PRq�E�PApREED FOR F�S:?gnaWeR ApspPS IIaew,. { g�'n '�• ALISg •9 iMB'.. SCO 1. ! wTl.mwo mb q � dna. tm lr e.uoeoeq:Lme a. vw ft Ono J A. ltJPl� �uNQ tt 4 tti� „ ALE ,' =. 2V DATE: Sept. 9, 2RUt H SEABDILDT. c L."_. Nt a9�E' 0.239 A AD 2:•- -" a 2.5 er f 2 9 N' P -L.. rn L-P. .' qyL. A 0 'To- r S v fif"? g :� .. '4"x.83' ''.c•cQ F ;' _ •k �� Dp `00 . . s o � +a .peg � � ;`�'� � •� ,$ 4 ,C*d £xi5�:a9 Corso. °i^ ' Seel ge- Pit k,To lv� A( Qe C,ro PARCEL SHOWN VtERIEQN REFERENCED HY',01ttO. RECORDED LN THE PUTNAM COVNTY CLERK'S OFFICE TN USER . 30 OF DEEDS AT PAGE 1'9$ Si10,IECT TO ELECTRIC AND/OR TELEPHONE TELEPHONE CO. CASEMENTS, IF ANY, FOR OVERHEAD AND /OR, UFMER^,ROUMD SERVICE SURL €'Fgl AS IN POSSCSSIC✓•I, (NO LMB6 of Po"bssidf an lv 7,»n ,fn dices t@O). SURSMUCrJRtES .AND /GR Ta Clk ENCODA64MENTS BELOW CRAOE, W ANY, NOT SHOttlbt, -INOSE OFFSETS TAKEN TO SIDING OR MIk PROPEP I-r CORNERS NOT 'STAKED. T fropose� l%Tsffi�Irr:oe So)( Propa�Se aLQ oLTOFt INN V t TH"5 SURVEY IS HEREBY CERTIFIED 'ONL;f 20: CER FIFiCATIQNS INDICATED NEREf'1a!1 51.OTIIPV THAT ?MI SORVEY WAS QHSPARED IN ACCdRDANOIL WTH THE . SkISTING CC*E OF PRACTTCE'P'OR LAND- SUR�S'Y9` I. AUSON M. SCOTT AOOPi1E0 BY THE MEIN YDRIC'STATE AFiSOC1AT(ON tW PRO"_ —.0NAL LAND SUR%MYORB. SAO C@RTYFi0ATT0P, / SHALL RUO dM-% TO THE 'P9R50N8., 0OR VNi Q_M. TIME. f[6�� RwEV IS PREPAPED AP40 ON TNETR B6NA�C' 10: i TITLE COMPANY; GOtIUWMENTAL A.GErfCY AM. I."M TUTION LASTED MEREON. ANO ;rd N U ro.yy� �F PUT1Vt4M VALLEY .AS51[t1NE6$ OF THE L—INDING 1NS17TVrON. CERTIFICATIONS Aft NOT TRANSFERABLE TO. ADDITFO{TAL wsmuII,ONS OFt SUB«OUENT OrlN[RS -M �-s�AA>� PV.TN PtLR COUNTY, f. N. . SURVEY OF PROPERTY IN. gym. as cap.o lna P1 PRq�E�PApREED FOR F�S:?gnaWeR ApspPS IIaew,. { g�'n '�• ALISg •9 iMB'.. SCO 1. ! TH"5 SURVEY IS HEREBY CERTIFIED 'ONL;f 20: LOCATED. FN I. AUSON M. SCOTT Z. FIRST 0,4ERIC,4N TVTLZ, INSURANCL r"PANT OF N(tW FORP"'_ c/° -TRI U ro.yy� �F PUT1Vt4M VALLEY -STATE AQS2R_AeT, Far Titl'* WO; ®29>i(T9i. 3. MIgWAt MO ?TOAD CO, IBC.. ILT 'S.,cC/O3a69 bnd /Cr :ASyign 9. -M �-s�AA>� PV.TN PtLR COUNTY, f. N. . J. HENRY C,,ARPF=NTER & CO'. IN. gym. as cap.o lna P1 LAND SUR VE'Y.Mr, aI< MAPPING. F�S:?gnaWeR ApspPS IIaew,. YORKTOFYN 'HEIGHTS. N-Y. wTl.mwo mb q � dna. tm lr e.uoeoeq:Lme a. vw ft Ono «.... ^«w.y G--- & t IIa lIl�aPr CaliW1 :11- Af{QYdt Z. lbjl v 5..,.y..d Res Pls . 9w "Nett; ft. o". • 4- *O: MW fAFY1T -I eh+Yy _ sY ! Pn, 0 M. Ss96", L a.. ,� YPPe avPonw iii 11f�lMlMtl N A! P!'t4d 9✓MJ. YI fl!phl SmKK2 I^� p' Pb Pt- tti� „ ALE ,' =. 2V DATE: Sept. 9, 2RUt H SEABDILDT. c L."_. Nt a9�E'