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'