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Home My WebLink About4156DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 83.74 -2 -34 BOX 32 LIS ' T 1.� . ly 1'6 I Z' 04156 PUTNAM COUNTY HEALTH DEPARTMENT DIVISION OF ENVIRONMENTAL HEALTH SERVICES PROPOSAL FOR SEWAGE DISPOSAL SYSTEM REPAIR YES NO Internal Use Only ❑ Repair Permit issued in last 5 years ❑ Not in Watershed ❑ ❑ Repair within Boyd's Comers, W. Branch or Croton Falls Res. ❑ Delegated ❑ ❑ Repair within 200 ft. of a watercourse or DEC - mapped wetland _ ❑ Joint Review SITE LOCATION � -- .- OWNER'S NAME D& -rvy� row M PHONE # MAILING ADDRESS 4& �r�v�� -�_ LAk-.,-- APPLICANT 'L.OVfS L.P�►,&-V �1 + 1,K/JIL d.- �oL, Cohn. Name & Relationship (i.e., owner, tenant, contractor) DATE G L�' — Q [,, FACILITY TYPE Si t:�$ cw►,. � PCHD COMPLAINT # mil.914 g 00 95" PROPOSED INSTALLER L epKi r1l; 4. sph CDk-St PHONE # . 9 /ft .2 3& W o ADDRESS LOtrO (v r eA1±1t KL+- 1� RE ISTRATION /LICENSE # PC 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 trenches) NOTE: Repair must be in same location and of same type as original sewage disposal system. Different location and proposed pump systems will require submittal of proposal from licensed professional anninaar nr ranic4arari nrrhi4arnf I, as owner, or reported agent of owner agree to the conditions stated on this form SIGNATURE TITLE C" eAq- DATE OF PrODosal aDDroved with the followinq conditions: 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 d. System description (e.g., 1250 gal. Concrete septic tank, etc.) e. Installers' name and phone number 3. System repair to be performed in .,_j3ccordance with the above proposal and conditio Pro sal Approved Proposal Denied �� 9al 0k) In ector's Signature & Title Date COPIES: White (PCHD); Yellow (Town BI); Pink (Installer), Orange (Applicant) PC -RP 99ML Rev. 8/05 r- Sheet—Lof ,k * T PUTyrI/��CnAyM COUNTY DEPARTMENT OF HEALTH �"TV119- .w�V � .t, ',{ ,'fi,Y T_#' ��,p,�47TM,,7``, Ti',J � .(. ., . 6"5 t{r FIELD ACTIVITY REPORT NAME: Tel. ADDRE , os- Street Town State Zip I" PERSON IN CIiARGE Ala O All a.61 E- (0 /2: // 0 (i iI Nam nd Title~ TYPE OF FACILITY: FIN 01NJGS: / 4&2s &V= —+ r� I I acknowledge receipt of this report: SIGNATURE: 02/96 Title: _ R ats rQ � a zrltt � Page No. of Pages LEONARDI & SON CONC&TMUCTION, INC. OWNER: LOUIS LEONARDI DRIVE - - - - - --Y 1056-------__,, r 7 _ 6 CAROLYN D E • CORTLANDT MANOR, N .. - LIC. #WC- 3112 -H90 • WC- SEPTIC LIC. #00067 • LIC. #PC -560 (CERTIFIED) PROPOSAL SUBMITTED TO PHONE r! DATE // STREET JOB NAME . r . _ _.._ ...._ i =• _ .- '-+ ..................... ............................... ............. .... ................... ( ............................................................................................ ............................... V" �J PLEASE'NOTE :. . .......... • SYSTEM' LONGEVrrY 'IS'NOT'GUARANTEEO'UNLESS DEStGNED'BY"A LICENSED'PROFEES10NAL ENGINEER'S *.............................. W .............................. 'TANK TO BE PUMPED BY OTHERS AND PAID SEPARATELY' 'NO LANDSCAPING RESTORATION, OTHER THAN GRADING DISTURBED AREAS, IS INCLUDED UNLESS SPECIFICALLY STATED.' Wr proPOSY hereby to furnish material and labor — complete in accordance with above specifications, for the sum of: ). Payment to be made as follows: dollars ($ CUSTOMER IS RESPONSIBLE FOR ANY AND ALL COLLECTION FEES. ALL DISPUTES ARE TO BE SETTLED THROUGH BINDING ARBITRATION. All material is guaranteed to be as specified. All work -to be completed in.a workmanlike manner according to standard practices. Any alteration or deviation from above specifications Authorized involving extra costs will be executed only upon written orders, and will become an extra Signature charge over and above the estimate. All agreements contingent upon strikes, accidents. or delays beyond our control. Owner to carry fire, tornado and other necessary insurance. Note: This proposal may be Our workers are fully covered by Workman's Compensation Insurance. withdrawn by us if not accepted-within days. Arre,ptaurr of PropaSaI —The above prices, specifications and conditions are satisfactory and are hereby accepted. You are authorized Signature to do the work as specified. Payment will be made as outlined above. Date of Acceptance: Signature , 1 w . .. F., 'iFr�.w� -. r +S r', � e+'. •rw O - O.- .. .. :,ky.:. : i• = F+i:_- .•+rte -.iy . .i.::4�- nk, YVAL Page No. of Pages prop to LE®NARDI . SON CONSTRUCTION, INC. OWNER: LOUIS LEONARDI 6 CAROLYN DRIVE .a CORTLAND7:_ MANOR, - NY..1.0567 .:.ror ; :m ed�.iyo +. -arc �� -r -�;, :` - w' -- -h-m P ^��- .tea.': �, '.°.a�— i- r.,�t -.:il � n"i :cr, °.fe•:v�' -.- v v ^i�a .. a. o, fr'•'"�'r; "::d - =v'�a _e:,yi$r'cvr..��- LIC. #WC= 3112 -H90 o WC- SEPTIC LIC. #00067 o LIC. #PC-560- (CERTIR ED) P.ROPOSA UBMITTED TO C2 r PHONE DATE STREET ` 4 JOB NAME CITY, STA E and ZIP CO 1-! ^ JOB LOCATION ARCHITECT DATE OF PLANS JOB PHONE We hereby submit specifications and estimates for: r ZZ f) �� Z- J7 2 PLEASE NONE: 'SYSTEM LONGEVITY IS Not GUARANTEED UNLESS DESIGNED BY A LfCENSED PROFEESIONAL ENGINEER.' 'rANK.T0 BE PUMPED BY OTHERS AND PAID SEPARATELY.' NO LANDSCAPING RESTORAn6N, OTHER THAN GRADING DISTURBED AREAS, IS INCLUDED UNLESS SPECIFICALLY STATED.' We Propose ; hereby to furnish material and labor = complete in accordance with above specifications, for the sum of: dollars ($ ). Payment to be made as follows: A FINANCE CHARGE OF 11/2% PER MONTH WILL BE ADDED TO ALL UNPAID BALANCES. GUSTOMER IS RESPONSIBLE FOR. ANY AND ALL COLLECTION FEES. ALL DISPUTES ARE TO BE SETTLED THROUGH BINDING ARBITRATION. All material is guaranteed to be as specified. All work to be completed in a workmanlike manner according to standard practices. Any alteration or deviation from above specifications Authorized involving extra costs will be executed only upon written orders, and will become an extra Signature charge over and above the estimate. All agreements contingent upon strikes; accidents or delays beyond our control:. Owner to carry fire; tornado and other necessary insurance. Note: This proposal-may be withdrawn by us if not accented within days- ArreptunCP o - piaposat —The above prices, specifications and conditions are satisfactory and are hereby ,accepted. You are authorized Signature to do the work as specified. Payment will be made as outlined above. Date of Acceptance: Signature PUTNAM COUNTY HEALTH DEPARTMENT • DIVISION OF ENVIRONMENTAL HEALTH SERVICES -PROPOSAL FOR.SE Stf D _ s- ES NO. Internal Use Only+ Repair Permit issued in last 5 years ❑ Not in Watershed ❑ ❑ Repair within Boyd's Comers, W. Branch or Croton Falls Res. ° ❑ Delegated, ❑ ❑ Repair within 2oo ft. of a watercourse or DEC - mapped wetland ❑ Joint Review SITE LOCATION �. OWNER'S NAMEt is ej .; `I PHONE # .MAILING ADDRESS i . APPLICANT Na mQ & Re(agiip. (.; ner, tenant, contractor} BATE FACILITY TYPE PCHD COMPLAINT# .PROPOSED INSTALLER RHONE # ADDRESS REGISTRATION /LICENSE # ro al (include a separate sketch locating the -house, property lines, all adjacent wells wlthin-360 feet of repair and the location of existing and proposed trenches) NOTE: Repair must be in same location and of,same type as original sewage disposal system. Different location and proposed pump systems ±still require submittal of proposal from licensed professional engineer or registered architect, 3 I, as owner, or reported agent of owner agree to the conditions stated on Jhis form SIGNATt4RE TITLE DATE ftgp_ gl gpp_rovep w1th the following conditions 1`: ' x 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 d. System description (e,g.,1250 gal. Concrete septic tank, etc.) e. Installers' name and phone number 3 System repair to be'perliormed in accordance with the above proposal and conditions. Proposal Approved Proposal Denied Inspectors Signature & Title' Date COPIES: White (PCHD); Yellow (Town Bl); Pink (Installer), Orange (Applicant) PC -RP 99ML Rev. 8/05 to iy