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HomeMy WebLinkAbout4137DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 83.74 -1 -30 BOX 32 ,I .. i,N% i - , �. rr + it r - Via 04137 .o PUTNAM COUNTY HEALTH DEPARTMENT DIVISION OF ENVIRONMENTAL HEALTH SERVICES Internal Use Only PERMIT-# s� Li ® Repair Permit issued in last 5 years ❑ of in Watershed ❑ . W,,.-'Repair within Boyd's Comers, W. Branch or Croton Falls Res. Delegated ❑ 13' within 200 ft. of a watercourse or DEC - mapped wetland ❑ Joint Review SITE LOCATION TOWN � . k ktk- \\ TM # q — OWNER'S NAME L.is PHONE# >0-17 MAILING ADDRESS \A �� �", �,,+ ��, ���� hy.Q APPLICANT 0 V,.,Am%,A — Name & Relationship (i.e., owner, tenant c n Tctor DATE 9<. L, Do( FACILITY TYPE S'L,,����Q PCHD COMPLAINT # PROPOSED INSTALLER ., Q. `'�i� Q� \O�._, PHONE # %k�4 - q\ . btZo ADDRESS Q(D 41ti REGISTRATION /LICENSE # � C3%5 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 con 'tions stated on this form SIGNATURE a TITLE DATE (owner) : . c sP septic. e lt _v , .9r or" n ' ^w.��-� of -th;s Permit t fo, t e'sapt. c s tCf f E ai�- Cr ply .� ... __..._ .__.a � - SIGNATURE C TITLE qyu_� DATE (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. 1W 1 CMNAL UJC UNLT Proposal Approved Proposal Denied ❑ Ins ector's Signature & 11ftle Dat4 I Expiration Date ,Repair proposal is in compliance with applicable codes Yes 0 No COPIES: PCHD; Owner; Installer PC -RP 99ML Rev. 2/07 p O� ,..M on v .Ord?►-. �►��ed�res . .e.,,. ,, ., � . �... r r . ,s � � . _ a:.:. 1. Determine amount needed to. purchase permit (Putnam County Health Dept is $150.00). 2. Obtain cash from Accounts Payable. If Accounts Payable is unavailable, get cash from Clint. If Clint is out of the office, call Clint or Dave. 3. Give cash to person buying money order. Instruct person buying money order where to purchase money order (use list below or look up on western union.com for location to purchase). 4. Instruct person buying money order to return receipt and stub for money order with paperwork. They can fill in the "Pay To" information at the place they are paying for permit. /--- Dutchess County A &P #094 Rte 44 & North Ave Pleasant Valley, NY 12569 845.635.1053 Hours: 8am —I Opm Pleasant Valley Post Office 1612 Main Street Pleasant Valley, NY 12569 845.635.8932 Hours: M — F 9am — 5pm Smokes 4 Less 17 North Ave Pleasant Valley, NY 12569 -7943 U 845.635.1053 Hours: M -F 9am — 8pm Sat 9am — 7pm _. ._._ ..... _. Putnam County A &P #154 Route 22 Brewster, NY 10509 845.278.5282 Hours: 9am — 8pm Hannaford Supermarket #325 1936 US Route 6 Carmel, NY 10512 845.225.4151 Hours: 7am — 9pm Rite Aid #3656 1511 Route 22 Suite A Lakeview Plaza Brewster, NY 10509 -4009 845.278.5251 Hours: gam — 9pm O r ,t �` n -y Cunniffe ' = Fc:r.l dri,�e north �.;. f La <e Peekskill NY 10537 Permit 9 R- 202 -09 :; t TM # 8374 -1 -30 , 7 As Built Drawing SHED j;: 'r D -BqX .. 11 1' A= 19'3" HOUSE TO INLET COVER C_. B= 7 3" HOUSE TO INLET COVER B 4 HOUSE }a C= 6' OUTLET COVER TO D -BOX - s; D= 10 9" OUT LET TO D -BOX HOUSE.'` �: , r l NOT TO SC ;LE NOT TO SCALE NOT TO SCA %E r O 0 i. ) cl� VII D cr�l