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Home My WebLink About4140DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 83.74 -1 -34 BOX 32 . . him ' 1 ' .' W. �r j,, V n 1601 6 '. ■ 04140 P V 1 � s PUTNAM COUNTY HEALTH DEPARTMENT I L t DIVISION OF ENVIRONMENTAL HEALTH SERVICES � .. .., ....e_ . PRtOPOSAL -POA 6Eii AGE-TR�M-E` T,WIS'i -kl; REPAII Internal Use 0 7w/'--- /_1 ❑ rRepair Repair Permit issued in last 5 years M Aot in Watershed ❑ Repair within Boyd's Comers, W. Branch or Croton Falls Res. y❑, Delegated within 200 ft. of a watercourse or DEC - mapped wetland ❑ Joint Review SITE LOCATION OWNER'S NAME MAILING ADDRESS APPLICANT �T i AN G 04 L, -� e,f " Name & Relationship (i.e., owner, tenant, contractor) M # 83.74.-1- 3+ PHONE #�� 255 DATE 1 i'?,1 FACILITY TYPE*, PCHD COMPLAINT # PROPOSED INSTALLER Z VA (.'t' L' P i co rA-S-t— PHONE # �/y 74 0 --i� ADDRESS � COJ,QMb -O hlg- P,,T (V U c4 REGISTRATION /LICENSE # I �7 Pro sal (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, ee to the con ' 'on stet on this form SIGNATURE TITLE DATE 3 3i i I, the septic install r, agree to comply with the conditions of this permit for the septic 6-*dM repair " SIGNATURE TITLE �G�c.� DATE (Installer) Proposal mums! 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 backfill until authorization to do so has been obtained from the Departmeft INTERNAL USE ONLY Proposal Approved a Proposal Denied ❑ lz�, Y// loL l® r� iture & Title I D to piration Date is in compliance with apDlicable codes Yes No O COPIES: PCHD; Owner; Installer PC -RP 99ML Rev. 2/07 V, j%no -t&yLaV;Ae_ ci 4k 0 g9 a6pz B2— `.NN 4 i(1s a�/ \ � !� __._ 170044' 43 rA) Z-1 . fA 9,0 Z/ -- I/ - Uar woo 000 9 _Z'!; 3 /70 _9x V_L9 610 o(e a-IV 107 r 41-t e, cx—v"C'n- �"�::t.�. :: a• armt.. .p "�RY''t�&.�<r'.+'�r"7"ftfv"�. '. �.M F. . � }i`eR:,t.Y - -,- :r`'., - t- ^+..- •c-t. PUTNAM COUNTY HEALTH DEPARTMENT DIVISION OF ENVIRONMENTAL HEALTH SERVICES r, Y a Fit N Internal Use On PERMIT � �,, 075—A! O . ,.Repair Permit issued in last 5 years /Not. in Watershed Repair. within Boyd's Comers, W. Branch or Croton Faiis Res: L — Delegated _..._ . _. .. : a Repair ,within Zoo it. of a watercourse or DEGmapped wetland El Joint Review. . SITE LOCATION TOWN La! La u % TM # 3 .74 – 1- - �--�— '�f R' NAME' PHONE # OWNER'S V 7t7rA � rt n��c�_ MAILING ADDRESS to n , , t� f� < < So APPLICANT, Name & Relationship Q.e., owner, tenant, contractor) DATE t 1 ?.`- FACILITY TYPE PCHD COMPLAINT# PROPOSED INSTALLER C'(.),A ST_ PHONE # -/ f Y -%L J � (�. /.`� ADDRESS JYLt�� ii v.{ �'��. Uc +��e4� REGISTRATION /LICENSE # P DMI (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. 1, as owner, to the to ' 'on stet on this form r. SIGNATURE TITLE ULA 's DATE., I, the septic install ,agree to comply with the conditions of ftiis permit for the septic system repair SIGNATURE .. ' TITLE DATE (Installer) Proposal ac zmW with the following conditions: r 1. Procurement of any Town Permit, if applicable. 12.' Submission of as built repair sketch by the septic system installer within 30 days of the repair, - in 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., I250 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 tD the &nation at which the -� v completed SSTS repair will function. 5. No completed work is to be badcfi urn authomation to do so has been obtained from the Department. EITERNAL USE.ONLY Proposal Approved Proposal Denied ❑ l! Q / toy Inspector's.Signature 8 Title Date ration .Date lRepair proposal is, in compliance wftKapblk able codes Yes No O COPIES: PCHD; Owner; Installer "CPC -RP 99ML Rev. 2107 PUTNANI. COU"iTY DEPARTTIVIENT OF HEALTH. DD-151ON OF EN-VIROTINNHEINT-A-L HEALTH SERVICES DESIGN DATA SFEET- E T -'S UB S UTRIA CE S lr-'WA GE TRE ATIVE N-T S Owner: Address: 10 ? Looted at (street)- T TY I R— Section: — Block— Lot Municipality; 1--V7-1V A14 VALLC)� Watershed SOIL PERCOLATION TEST DATA Witnessed by: — Date'of Pre-soakifilu. Date of Percolation Tes.t:- i Hole No. Run Rio. Time Start— Stop ( Elapse Time (min.) Depth to I water from round I = surface (inches.) Start - Stop ater level drop in inches Percolation Rate min/inch ...... . � - - ._ - - . L .._. -_ . - -� - - is �- I 3 .4 2 1 I I j 2 4 4 .3 4 No C e 5: I T-q7--, rn hp re^,P-r?51' ir -t-nrh 11r,.r:1 C EP"T ',- F C; L E: I I HOLE -� I- C. L 0.5, 1.01 TEST PIT D.-TA cu; H 0 L -E # HOLE # F.(-';L- -- 2.G' Z. -7 3.5' 0 "'NMA e, 4.c. - TO' '7 ffid-kate level at w1iich z7oundwaie-, is encountered! A11011\140—r- Indicate level at w1uch -motilinc, is observed AZO m In, ul i -- 3.-T2 lvv��t to w�lch water tevel tises a:-L�— being �--,,coun.tcred C— -.D a --..e Deep hole obse—rvation—, made b.-,;: 61 jj Z, , ly,T Desia,--n- Address.. c : I ii \"_ ! 'k 'r 4-0 - -,A,t Uj 11 1; Uell ji.94 -Alv-f A MU -Powr *DlZ. 5oa7-// _PV7_/VA,A V4.1 p y T,A4# $31741- - 3 '/ dv') 0 o we // LAKE PEEKSKILL, /NYC r :�9 RPUTNAM COUNTY, �NY'�. :o. -.:p: 'hereon.. are va!id for the map and copies aid anap or copies beat the impressed, Ayer Whose: Signature appears herecnrl." / 17" A/0 / .- sTA 1<,E -7o" . DUE FAST 60.00 ' B0AAPO FENCE 40.70 P •a 0.50.' . 0.5 y. i o v U,e , to � 2 - o J 6 lksrY o J r � F� K/OOp Dec EL 14' t4 D eel smill I W6 1/0 . . . . . . . . . . . . PUTNAM VALLEY m 1 201 ST 1 Town Park: A ro tu In 3 DR R Lu LIT-- Ch 'Y LA 21 py BROOK LA osq yea %41L /1 �-q2 PUTNAM CaRM HEALTH DEPARTMENT DIVISION OF ENVIRONMENTAL HEALTH SERVICES 225- 0310 :....: PROPOSAL FOR SEWAGE DISPOSAL SYSTEM REPAIR OWNER' s NAIL i n L n "'� Lo r r c ti n z, T wi n o h e-.. SITE LOCATION i0 Poll 0 MAILING ADDRESS 10 P01 `i n b r o +� Lu T PHONE 9 1q 5 , % - N5 0 J3L Jt,Sxc..A 1 p S'. PERSON INTERVIEWED Lo r t co n q -, I ah n e WC PC HD Complaint # Name & Relationship (i.e, own ,tenant, etc.) i DATE r1"C`1.\1.A 1 i l � q TYPE FACILITY 3 BCQroCm HoM PROPOSED INSTALLER je PHONE 7 3 °l ' S' 2—r 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 fran licensed professional engineer or registered architect. Proposal Inspector's Signature & Title Proposal Disapproved S nau Proposal approved with the following conditions: 1. Procurement of any Town permit, if applicable. 2. Submission 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 owneifi, or reported agent of owner agree to the above conditions. SIGNATURE TITLE y� Own L r— DATE 5 t � C� t� 3MM: Write (PCED): YeUcw (Tam HU; Pink (An2ir.BYt) AAe P6Po5r—o p R y /Ll y 7z) 5 74 Z �A 14 ds37 PC//Y7- C9 I" T172